Provider Demographics
NPI:1194874966
Name:PAMELLA S GRONEMEYER
Entity type:Organization
Organization Name:PAMELLA S GRONEMEYER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELLA
Authorized Official - Middle Name:SUZZANNE
Authorized Official - Last Name:GRONEMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-651-8097
Mailing Address - Street 1:1280 MERCANTILE DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1256
Mailing Address - Country:US
Mailing Address - Phone:618-654-8985
Mailing Address - Fax:618-651-8097
Practice Address - Street 1:1270 MERCANTILE DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249
Practice Address - Country:US
Practice Address - Phone:618-651-8097
Practice Address - Fax:618-651-8097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0105X
IL207ZP0105X291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL575343394Medicaid
IL036062202Medicaid
IL036043088Medicaid
ILCK0761OtherRR MEDICARE PIN
IL036050692Medicaid
IL036054213Medicaid
IL036057055Medicaid
IL036057055Medicaid
IL036062202Medicaid
IL036057055Medicaid
IL220011628Medicare PIN
ILCK0761OtherRR MEDICARE PIN
IL036043088Medicaid
IL036050692Medicaid
ILIL7225002Medicare PIN