Healthcare Provider Details

I. General information

NPI: 1366419632
Provider Name (Legal Business Name): NICHOLAS J. PALERMO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 E CENTER ST THE OPTIMUM HEALTH BUILDING
MANCHESTER CT
06040-5214
US

IV. Provider business mailing address

49 ERIE ST
MANCHESTER CT
06040-7034
US

V. Phone/Fax

Practice location:
  • Phone: 860-645-3927
  • Fax: 860-643-2531
Mailing address:
  • Phone: 860-647-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberCT000151
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: