Provider Demographics
NPI:1154580447
Name:GOODELL, PAMELA PINEDA (MD)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:PINEDA
Last Name:GOODELL
Suffix:
Gender:F
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:PO BOX 60070
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-0070
Mailing Address - Country:US
Mailing Address - Phone:866-759-4528
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-672-4964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228357207ZP0102X
PAMD439244207ZP0102X
IL036.128458207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03612845801Medicaid
ILP00971579OtherRAILROAD MEDICARE
IL03612845801Medicaid