Healthcare Provider Details

I. General information

NPI: 1093797144
Provider Name (Legal Business Name): MICHAEL J PALKO III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E OGLETHORPE HWY
HINESVILLE GA
31313
US

IV. Provider business mailing address

2400 BELLEVUE RD SUITE 21-A
DUBLIN GA
31021-2885
US

V. Phone/Fax

Practice location:
  • Phone: 912-369-7546
  • Fax: 478-328-0438
Mailing address:
  • Phone: 478-275-7202
  • Fax: 478-274-8418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number049863
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number049863
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: