Provider Demographics
NPI:1255360855
Name:PALMISANO, GLEN MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:MICHAEL
Last Name:PALMISANO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 LANDSHARK BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32124-3727
Mailing Address - Country:US
Mailing Address - Phone:860-751-8501
Mailing Address - Fax:
Practice Address - Street 1:633 LANDSHARK BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-3727
Practice Address - Country:US
Practice Address - Phone:860-585-9797
Practice Address - Fax:860-589-9002
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5911111N00000X
CT000681111N00000X, 111NR0400X
FL5711111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050000681CT01OtherANTHEM BCBS PROVIDER ID
CT793437OtherCONNECTICARE PROVIDER ID
CT350000521Medicare ID - Type UnspecifiedPROVIDER NUMBER MEDICARE
CT050000681CT01OtherANTHEM BCBS PROVIDER ID