Basic Information
| Provider Information | |||||||||
| NPI: | 1700819133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOMMIASAMY | ||||||||
| FirstName: | VEERASIKKU | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960416 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774854474 | ||||||||
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| Practice Location | |||||||||
| Address1: | 695 N KELLOGG ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614012807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3093438131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 08/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036051814 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 36051814 | 01 | IL | BLUE SHIELD | OTHER | 0360518141 | 05 | IL | MEDICAID | 0360518146 | 05 | IL | MEDICAID | P00347048 | 01 | IL | RAILROAD MEDICARE | OTHER | P00936471 | 01 | IL | RRMCARE THRU CESIISC (GES) | OTHER |