Healthcare Provider Details

I. General information

NPI: 1821075383
Provider Name (Legal Business Name): PHORNPHAT RASAMIMARI M.D., MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MACARTHUR BLVD NEONATOLOGY DEPARTMENT
MUNSTER IN
46321-2901
US

IV. Provider business mailing address

9201 CALUMET AVE
MUNSTER IN
46321-2807
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-2022
  • Fax:
Mailing address:
  • Phone: 219-836-2022
  • Fax: 219-836-0034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-098723
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036-098723
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01060038A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01060038A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: