Healthcare Provider Details

I. General information

NPI: 1578603668
Provider Name (Legal Business Name): HENRY R PALMER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 N WILTON AVE 2ND
CHICAGO IL
60657-6710
US

IV. Provider business mailing address

3048 N WILTON AVE 2ND
CHICAGO IL
60657-6710
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-5424
  • Fax: 773-296-5280
Mailing address:
  • Phone: 773-296-5424
  • Fax: 773-296-5280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036052930
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: