Healthcare Provider Details

I. General information

NPI: 1194874966
Provider Name (Legal Business Name): PAMELLA S GRONEMEYER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 MERCANTILE DR
HIGHLAND IL
62249
US

IV. Provider business mailing address

1280 MERCANTILE DR
HIGHLAND IL
62249-1256
US

V. Phone/Fax

Practice location:
  • Phone: 618-651-8097
  • Fax: 618-651-8097
Mailing address:
  • Phone: 618-654-8985
  • Fax: 618-651-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number207ZP0105X
License Number StateIL

VIII. Authorized Official

Name: DR. PAMELLA SUZZANNE GRONEMEYER
Title or Position: SOLE PROPIETOR
Credential: MD
Phone: 618-651-8097