=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053316893
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY JOHN PALMER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7073 CLYO RD
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45459-4816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-435-5857
-----------------------------------------------------
Fax | 937-912-4960
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36115 SCHOOLCRAFT RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48150-1216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-464-0887
-----------------------------------------------------
Fax | 734-402-0254
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35-07-7315-P
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------