Healthcare Provider Details

I. General information

NPI: 1831336379
Provider Name (Legal Business Name): PAM EERNISSE DPM SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MICHIGAN AVE SUITE 720
CHICAGO IL
60602-3402
US

IV. Provider business mailing address

9050 W 81ST ST
JUSTICE IL
60458-1350
US

V. Phone/Fax

Practice location:
  • Phone: 312-701-0770
  • Fax: 312-701-0705
Mailing address:
  • Phone: 708-594-3500
  • Fax: 708-594-3526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016004918
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. PAMELA ANN EERNISSE
Title or Position: OWNER
Credential: DPM
Phone: 312-701-0770