Provider Demographics
NPI:1194077339
Name:CATHERINE BOMBERGER, MD, LLC
Entity type:Organization
Organization Name:CATHERINE BOMBERGER, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOMBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-464-1933
Mailing Address - Street 1:310 HOSPITAL DR
Mailing Address - Street 2:BLDG B, SUITE 315
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3895
Mailing Address - Country:US
Mailing Address - Phone:478-464-1933
Mailing Address - Fax:478-464-5094
Practice Address - Street 1:310 HOSPITAL DR
Practice Address - Street 2:BLDG B, SUITE 315
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3895
Practice Address - Country:US
Practice Address - Phone:478-464-1933
Practice Address - Fax:478-464-5094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048188207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00875476AMedicaid
GA11BDRTPOtherMEDICARE PTAN
GAH15747Medicare UPIN