Provider Demographics
NPI:1700819133
Name:BOMMIASAMY, VEERASIKKU (MD)
Entity Type:Individual
Prefix:
First Name:VEERASIKKU
Middle Name:
Last Name:BOMMIASAMY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 960416
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0001
Mailing Address - Country:US
Mailing Address - Phone:877-485-4474
Mailing Address - Fax:
Practice Address - Street 1:695 N KELLOGG ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2807
Practice Address - Country:US
Practice Address - Phone:309-343-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036051814207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36051814OtherBLUE SHIELD
IL0360518141Medicaid
IL0360518146Medicaid
ILP00347048OtherRAILROAD MEDICARE
ILP00936471OtherRRMCARE THRU CESIISC (GES)
ILP00936471OtherRRMCARE THRU CESIISC (GES)
ILK30920Medicare PIN
ILC45130Medicare UPIN