Healthcare Provider Details

I. General information

NPI: 1205975968
Provider Name (Legal Business Name): BRIDGETON FOOT AND ANKLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 DE PAUL DR STE. 470
BRIDGETON MO
63044-2510
US

IV. Provider business mailing address

12255 DE PAUL DR STE. 470
BRIDGETON MO
63044-2510
US

V. Phone/Fax

Practice location:
  • Phone: 314-739-8863
  • Fax: 314-739-6448
Mailing address:
  • Phone: 314-739-8863
  • Fax: 314-739-6448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000551
License Number StateMO

VIII. Authorized Official

Name: DR. ANTHONY M LOMBARDO
Title or Position: PHYSICIAN
Credential: D.P.M.
Phone: 314-739-8863