Provider Demographics
NPI:1386602100
Name:ZIMMERMAN, RAYMOND (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:ZIMMERMAN
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 1:8777 BROADWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6693
Mailing Address - Country:US
Mailing Address - Phone:219-756-0960
Mailing Address - Fax:219-756-0961
Practice Address - Street 1:8777 BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6693
Practice Address - Country:US
Practice Address - Phone:219-756-0960
Practice Address - Fax:219-756-0961
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035397A207Q00000X
IL036-081831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081831Medicaid
IN200152060Medicaid
IL0222075OtherBLUE CROSS GROUP NUMBER
IL3631498336019001OtherCDPG HFS PAYEE ID
ILP00700171OtherRR MEDICARE
IL363149833OtherTAX IDENTIFICATION NUMBER
IL178481Medicare PIN
IL0222075OtherBLUE CROSS GROUP NUMBER
IL363149833OtherTAX IDENTIFICATION NUMBER
IN200152060Medicaid