Provider Demographics
NPI:1205975968
Name:BRIDGETON FOOT AND ANKLE LLC
Entity type:Organization
Organization Name:BRIDGETON FOOT AND ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOMBARDO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:314-739-8863
Mailing Address - Street 1:12255 DE PAUL DR
Mailing Address - Street 2:STE. 470
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2510
Mailing Address - Country:US
Mailing Address - Phone:314-739-8863
Mailing Address - Fax:314-739-6448
Practice Address - Street 1:12255 DE PAUL DR
Practice Address - Street 2:STE. 470
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-739-8863
Practice Address - Fax:314-739-6448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000551213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2700030OtherUHC
MO480034196OtherRR MEDICARD
MO32B00000XOtherMEDICAID DME
MO2784098OtherUHC
MOP00419552OtherRR MEDICARE
MO303231500Medicaid
MO300628401Medicaid
MO310171750OtherMEDICARE CPIN
MO504595802OtherMEDICAID GROUP
MO32B00000XOtherMEDICAID DME
MO4637400001Medicare NSC
MO2700030OtherUHC