1306834346 NPI number — PREMIER PATHOLOGY SERVICES LLC

Table of content: (NPI 1306834346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306834346 NPI number — PREMIER PATHOLOGY SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PATHOLOGY SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306834346
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 144333
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32814-4333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-422-9831
Provider Business Mailing Address Fax Number:
407-648-2065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 S 3RD ST
Provider Second Line Business Practice Location Address:
DEPT. OF PATHOLOGY
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62220-1915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-234-2120
Provider Business Practice Location Address Fax Number:
618-222-4630
Provider Enumeration Date:
10/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAEGE
Authorized Official First Name:
DOLPH
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
618-234-2120

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 241644 . This is a "ADVANTRA PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 717892 . This is a "HEALTHLINK PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 08232162 . This is a "BCBS IL PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 241644 . This is a "GHP PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DD7836 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 507261808 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 241644 . This is a "CMR PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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