Basic Information
| Provider Information | |||||||||
| NPI: | 1194874966 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAMELLA S GRONEMEYER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SEMC PATHOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1280 MERCANTILE DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622491256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186548985 | ||||||||
| FaxNumber: | 6186518097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1270 MERCANTILE DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186518097 | ||||||||
| FaxNumber: | 6186518097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 11/22/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRONEMEYER | ||||||||
| AuthorizedOfficialFirstName: | PAMELLA | ||||||||
| AuthorizedOfficialMiddleName: | SUZZANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE PROPIETOR | ||||||||
| AuthorizedOfficialTelephone: | 6186518097 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 291U00000X | 207ZP0105X | IL | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 575343394 | 05 | IL | MEDICAID | 036062202 | 05 | IL | MEDICAID | 036043088 | 05 | IL | MEDICAID | CK0761 | 01 | IL | RR MEDICARE PIN | OTHER | 036050692 | 05 | IL | MEDICAID | 036054213 | 05 | IL | MEDICAID | 036057055 | 05 | IL | MEDICAID |