=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366419632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS J. PALERMO D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 257 E CENTER ST THE OPTIMUM HEALTH BUILDING
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-5214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-645-3927
-----------------------------------------------------
Fax | 860-643-2531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 ERIE ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-7034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-647-7055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | CT000151
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------