MEDICARE: DR. LEONARD V RIDILLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MA05731800	PA

General Provider Information

NPI Number	:	1568468692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEONARD V RIDILLA MD

Provider Business Mailing Address
First Line	:	15 E REDMAN AVE
Second Line	:
City	:	HADDONFIELD
State	:	NJ
Zip	:	08033-2316
Country	:	US
Telephone Number	:	856-428-1335
Fax Number	:	856-428-6334

Provider Business Practice Location Address
First Line	:	15 E REDMAN AVE
Second Line	:
City	:	HADDONFIELD
State	:	NJ
Zip	:	08033-2316
Country	:	US
Telephone Number	:	856-428-1335
Fax Number	:	856-428-6334

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	02/02/2010

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