Provider Demographics
NPI:1659481778
Name:BROMBERG, MERRICK JAY (DO)
Entity Type:Individual
Prefix:DR
First Name:MERRICK
Middle Name:JAY
Last Name:BROMBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:303 W LAKE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2586
Mailing Address - Country:US
Mailing Address - Phone:630-543-3020
Mailing Address - Fax:630-543-1551
Practice Address - Street 1:303 W LAKE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2586
Practice Address - Country:US
Practice Address - Phone:630-543-3020
Practice Address - Fax:630-543-1551
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-060761208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060761Medicaid