Provider Demographics
NPI:1154321107
Name:CAMMENGA, RANDALL J (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
Last Name:CAMMENGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3371 CLEVELAND ROAD EXT
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9780
Mailing Address - Country:US
Mailing Address - Phone:574-271-2558
Mailing Address - Fax:574-273-1137
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-523-3161
Practice Address - Fax:574-523-3221
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-03-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01041177207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000082225OtherAANTHEM
IN000000082225OtherAANTHEM
F40631Medicare UPIN