=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396772018
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIKE JOHN PALMISANO MS ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4402 CHURCHMAN AVE SUITE 103
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40215-1190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-361-5253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7400 WOLFPEN WOODS CT
-----------------------------------------------------
City | PROSPECT
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40059-7106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT112
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------