MEDICARE: TOBY J. PALM O.D., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2872T	OR

General Provider Information

NPI Number	:	1407969322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOBY J. PALM O.D., P.C.

Provider Business Mailing Address
First Line	:	145 MYRTLE ST
Second Line	:	SUITE 108
City	:	SUTHERLIN
State	:	OR
Zip	:	97479-9113
Country	:	US
Telephone Number	:	541-459-4333
Fax Number	:	541-459-7512

Provider Business Practice Location Address
First Line	:	145 MYRTLE ST
Second Line	:	SUITE 108
City	:	SUTHERLIN
State	:	OR
Zip	:	97479-9113
Country	:	US
Telephone Number	:	541-459-4333
Fax Number	:	541-459-7512

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	DR. TOBY J PALM
Credential	:	O.D.
Telephone Number	:	541-459-4333

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	01/24/2008

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