Provider Demographics
NPI:1821075383
Name:RASAMIMARI, PHORNPHAT (MD, MPH)
Entity Type:Individual
Prefix:
First Name:PHORNPHAT
Middle Name:
Last Name:RASAMIMARI
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2807
Mailing Address - Country:US
Mailing Address - Phone:219-836-2022
Mailing Address - Fax:219-836-0034
Practice Address - Street 1:901 MACARTHUR BLVD
Practice Address - Street 2:NEONATOLOGY DEPARTMENT
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2901
Practice Address - Country:US
Practice Address - Phone:219-836-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-098723208000000X, 2080N0001X
IN01060038A208M00000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200510260Medicaid
IN000000964820OtherANTHEM PROVIDER NUMBER
INM471400271OtherMEDICARE
IN200510260Medicaid