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NPI Code Detail

MEDICARE: PREMIER PATHOLOGY SERVICES LLC

MEDICARE: PREMIER PATHOLOGY SERVICES LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207ZP0102XAnatomic Pathology & Clinical Pathology PhysicianIL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
5DD7836OTHERILMEDICARE RAILROAD

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1241644OTHERILADVANTRA PIN
2717892OTHERILHEALTHLINK PIN
308232162OTHERILBCBS IL PIN
4241644OTHERILGHP PIN
6MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7241644OTHERILCMR PIN

General Provider Information

NPI Number : 1306834346
Entity Type Code : Organization
Provider Name (Legal Business Name) : PREMIER PATHOLOGY SERVICES LLC
Provider Business Mailing Address
First Line : PO BOX 144333
Second Line :
City : ORLANDO
State : FL
Zip : 32814-4333
Country : US
Telephone Number : 407-422-9831
Fax Number : 407-648-2065
Provider Business Practice Location Address
First Line : 211 S 3RD ST
Second Line : DEPT. OF PATHOLOGY
City : BELLEVILLE
State : IL
Zip : 62220-1915
Country : US
Telephone Number : 618-234-2120
Fax Number : 618-222-4630
Authorized Official
Title or Position : PRESIDENT
Name : DOLPH D HAEGE
Credential : MD
Telephone Number : 618-234-2120
Provider Enumeration Date : 10/13/2005
Last Update Date : 07/21/2022

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Directions to “PREMIER PATHOLOGY SERVICES LLC ” Practice Location

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