MEDICARE: DR. MARIO LAWRENCE PALERMO O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046007444	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1684526	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1104806348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIO LAWRENCE PALERMO O.D.

Provider Business Mailing Address
First Line	:	18 S EVERGREEN AVE
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1428
Country	:	US
Telephone Number	:	847-253-8500
Fax Number	:	847-253-8538

Provider Business Practice Location Address
First Line	:	18 S EVERGREEN AVE
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1428
Country	:	US
Telephone Number	:	847-253-8500
Fax Number	:	847-253-8538

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	01/29/2010

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