Provider Demographics
NPI:1427036151
Name:EERNISSE, PAMELA A (DPM)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:EERNISSE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-0967
Mailing Address - Country:US
Mailing Address - Phone:312-337-2468
Mailing Address - Fax:312-337-6912
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:708-594-3500
Practice Address - Fax:708-594-3524
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16004918213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202897Medicare ID - Type Unspecified
ILU76023Medicare UPIN
IL202944/L93800Medicare ID - Type Unspecified
IL202898/L93711Medicare ID - Type Unspecified
5747540002Medicare NSC
5747540001Medicare NSC