Provider Demographics
NPI:1629367081
Name:PALMISANO, ERICA LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNNE
Last Name:PALMISANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3185 MACATAWA DR SW STE B
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3184
Mailing Address - Country:US
Mailing Address - Phone:616-531-6900
Mailing Address - Fax:
Practice Address - Street 1:3185 MACATAWA DR SW STE B
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-3184
Practice Address - Country:US
Practice Address - Phone:616-531-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036135083207K00000X
MI4301501657207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036135083Medicaid
ILF400311917Medicare PIN