Basic Information
| Provider Information | |||||||||
| NPI: | 1427036151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EERNISSE | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 967 | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604770967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123372468 | ||||||||
| FaxNumber: | 3123376912 | ||||||||
| Practice Location | |||||||||
| Address1: | 9050 W 81ST ST | ||||||||
| Address2: | |||||||||
| City: | JUSTICE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604581350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085943500 | ||||||||
| FaxNumber: | 7085943524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 02/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 16004918 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.