Provider Demographics
NPI:1417083080
Name:PAM EERNISSE DPM SC
Entity Type:Organization
Organization Name:PAM EERNISSE DPM SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAM
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:EERNISSE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-594-3500
Mailing Address - Street 1:9050 W 81ST ST
Mailing Address - Street 2:
Mailing Address - City:JUSTICE
Mailing Address - State:IL
Mailing Address - Zip Code:60458-1350
Mailing Address - Country:US
Mailing Address - Phone:708-594-3500
Mailing Address - Fax:708-594-3526
Practice Address - Street 1:9050 W 81ST ST
Practice Address - Street 2:
Practice Address - City:JUSTICE
Practice Address - State:IL
Practice Address - Zip Code:60458-1350
Practice Address - Country:US
Practice Address - Phone:708-325-1050
Practice Address - Fax:708-594-3526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004918213ES0103X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5747540001Medicare NSC