Provider Demographics
NPI:1235150939
Name:BOMMARITO, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:BOMMARITO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7905 CALUMET AVE
Mailing Address - Street 2:HAMMOND CLINIC LLC
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1215
Mailing Address - Country:US
Mailing Address - Phone:219-836-5800
Mailing Address - Fax:219-836-8073
Practice Address - Street 1:7905 CALUMET AVE
Practice Address - Street 2:HAMMOND CLINIC LLC
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1215
Practice Address - Country:US
Practice Address - Phone:219-836-5800
Practice Address - Fax:219-836-8073
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062187A207RP1001X
IN01062187207RC0200X, 207RS0012X
IL036108719207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200832730Medicaid
IN473060V6Medicare ID - Type Unspecified
IN200832730Medicaid