Provider Demographics
NPI:1821030099
Name:PALMER, BRADY M (OD)
Entity type:Individual
Prefix:DR
First Name:BRADY
Middle Name:M
Last Name:PALMER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2207
Mailing Address - Country:US
Mailing Address - Phone:931-455-1800
Mailing Address - Fax:931-455-3124
Practice Address - Street 1:2111 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2207
Practice Address - Country:US
Practice Address - Phone:931-455-1800
Practice Address - Fax:931-455-3124
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2012-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD2300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7315742OtherCIGNA
919218OtherBLOCK VISION
TN3944518Medicaid
2240579OtherUHC
1024582OtherBCBS
3944518Medicare ID - Type Unspecified
2240579OtherUHC