Healthcare Provider Details

I. General information

NPI: 1437354099
Provider Name (Legal Business Name): MATTHEW MICHAEL PALMER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 BOTTINEAU BLVD SUITE 210
CRYSTAL MN
55429
US

IV. Provider business mailing address

5700 BOTTINEAU BLVD SUITE 210
CRYSTAL MN
55429
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-7000
  • Fax: 763-587-7015
Mailing address:
  • Phone: 810-232-3522
  • Fax: 810-762-4526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5101017155
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number56675
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: