1194874966 NPI number — PAMELLA S GRONEMEYER

Table of content: (NPI 1194874966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194874966 NPI number — PAMELLA S GRONEMEYER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAMELLA S GRONEMEYER
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:
6
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:
1194874966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1280 MERCANTILE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIGHLAND
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62249-1256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-654-8985
Provider Business Mailing Address Fax Number:
618-651-8097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1270 MERCANTILE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGHLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-651-8097
Provider Business Practice Location Address Fax Number:
618-651-8097
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRONEMEYER
Authorized Official First Name:
PAMELLA
Authorized Official Middle Name:
SUZZANNE
Authorized Official Title or Position:
SOLE PROPIETOR
Authorized Official Telephone Number:
618-651-8097

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 207ZP0105X , 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: 575343394 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036062202 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036043088 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CK0761 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036050692 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036054213 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036057055 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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