Provider Demographics
NPI:1306834346
Name:PREMIER PATHOLOGY SERVICES LLC
Entity Type:Organization
Organization Name:PREMIER PATHOLOGY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOLPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAEGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-234-2120
Mailing Address - Street 1:PO BOX 144333
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-4333
Mailing Address - Country:US
Mailing Address - Phone:407-422-9831
Mailing Address - Fax:407-648-2065
Practice Address - Street 1:211 S 3RD ST
Practice Address - Street 2:DEPT. OF PATHOLOGY
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1915
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:618-222-4630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL241644OtherADVANTRA PIN
IL717892OtherHEALTHLINK PIN
IL08232162OtherBCBS IL PIN
IL241644OtherGHP PIN
ILDD7836OtherMEDICARE RAILROAD
MO507261808Medicaid
IL241644OtherCMR PIN
IL717892OtherHEALTHLINK PIN