1386697274 NPI number — MARY K PALMORE MD SC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386697274 NPI number — MARY K PALMORE MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARY K PALMORE MD SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386697274
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5543
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60680-5543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-779-8285
Provider Business Mailing Address Fax Number:
773-779-8420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3641 E 108TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60617-6951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-731-5466
Provider Business Practice Location Address Fax Number:
773-731-5461
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PALMORE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
773-779-8285

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 14D0996652 . This is a "CLIA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: DG8319 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 01627483 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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