Provider Demographics
NPI:1598824203
Name:PALMER-HALL, ANITA (OD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:PALMER-HALL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3865 N MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5603
Mailing Address - Country:US
Mailing Address - Phone:815-399-2190
Mailing Address - Fax:815-399-5543
Practice Address - Street 1:3865 N MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5603
Practice Address - Country:US
Practice Address - Phone:815-399-2190
Practice Address - Fax:815-399-5543
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009409152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4519570OtherBCBS
IL4519570OtherBCBS
IL4519570OtherBCBS
IL46009409Medicaid
ILK10792Medicare ID - Type Unspecified