Provider Demographics
NPI:1386697274
Name:MARY K PALMORE MD SC
Entity type:Organization
Organization Name:MARY K PALMORE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:PALMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-779-8285
Mailing Address - Street 1:PO BOX 5543
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-5543
Mailing Address - Country:US
Mailing Address - Phone:773-779-8285
Mailing Address - Fax:773-779-8420
Practice Address - Street 1:3641 E 108TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-6951
Practice Address - Country:US
Practice Address - Phone:773-731-5466
Practice Address - Fax:773-731-5461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D0996652OtherCLIA
ILDG8319OtherRAILROAD MEDICARE
IL01627483OtherBCBS
IL706940Medicare PIN