Provider Demographics
NPI:1831194133
Name:PALMER, GREG (MD)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:PALMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:D
Other - Middle Name:GREG
Other - Last Name:PALMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:107 BRIDGEWAY ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:AURORA
Mailing Address - State:IN
Mailing Address - Zip Code:47001-1378
Mailing Address - Country:US
Mailing Address - Phone:812-926-0814
Mailing Address - Fax:812-926-2825
Practice Address - Street 1:107 BRIDGEWAY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:AURORA
Practice Address - State:IN
Practice Address - Zip Code:47001-1378
Practice Address - Country:US
Practice Address - Phone:812-926-0814
Practice Address - Fax:812-926-2825
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052001207N00000X
IN01033594A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0777379Medicaid
IN200895910Medicaid
IN200895910Medicaid
P00645747Medicare PIN
IN172580IIMedicare PIN
INE35720Medicare UPIN
OH4270011Medicare PIN