Provider Demographics
NPI:1033418140
Name:PALMER, JACQUELYN ANNE VIRGI (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ANNE VIRGI
Last Name:PALMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:ANNE
Other - Last Name:VIRGI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3000 MACK RD
Mailing Address - Street 2:STE. 2531
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5335
Mailing Address - Country:US
Mailing Address - Phone:513-924-8535
Mailing Address - Fax:513-924-8559
Practice Address - Street 1:3000 MACK RD
Practice Address - Street 2:STE. 2531
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-5335
Practice Address - Country:US
Practice Address - Phone:513-924-8535
Practice Address - Fax:513-924-8559
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT194821208600000X
NC2014-00901208600000X
OH35126992208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0140445Medicaid
SCNC2134Medicaid
NC1033418140Medicaid
OH0140445Medicaid
NC1033418140Medicaid