Provider Demographics
NPI:1295793107
Name:MACKIE, PALMER J (MD)
Entity type:Individual
Prefix:
First Name:PALMER
Middle Name:J
Last Name:MACKIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11725 ILLINOIS ST STE 250
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3015
Practice Address - Country:US
Practice Address - Phone:317-688-5300
Practice Address - Fax:317-688-5313
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044359A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200067280Medicaid
IN000000086733OtherANTHEM
IN000000086733OtherANTHEM
ING19847Medicare UPIN