Basic Information
| Provider Information | |||||||||
| NPI: | 1306834346 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER PATHOLOGY SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 144333 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328144333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074229831 | ||||||||
| FaxNumber: | 4076482065 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 S 3RD ST | ||||||||
| Address2: | DEPT. OF PATHOLOGY | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622201915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182342120 | ||||||||
| FaxNumber: | 6182224630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | HAEGE | ||||||||
| AuthorizedOfficialFirstName: | DOLPH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6182342120 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 241644 | 01 | IL | ADVANTRA PIN | OTHER | 717892 | 01 | IL | HEALTHLINK PIN | OTHER | 08232162 | 01 | IL | BCBS IL PIN | OTHER | 241644 | 01 | IL | GHP PIN | OTHER | DD7836 | 01 | IL | MEDICARE RAILROAD | OTHER | 507261808 | 05 | MO | MEDICAID | 241644 | 01 | IL | CMR PIN | OTHER |