Basic Information
| Provider Information | |||||||||
| NPI: | 1982992467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALMER | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6006 EUNICE AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212141809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109496639 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4337 EBENEZER RD | ||||||||
| Address2: | |||||||||
| City: | NOTTINGHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212362143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105293303 | ||||||||
| FaxNumber: | 4105297980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2011 | ||||||||
| LastUpdateDate: | 07/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 23692 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | KCH3 | 01 | MD | BLUE CROSS OF MARYLAND | OTHER |