Provider Demographics
NPI:1124441308
Name:PACKER MEDICAL SERVICES,LLC
Entity type:Organization
Organization Name:PACKER MEDICAL SERVICES,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MILFORD
Authorized Official - Last Name:PACKER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:912-283-2311
Mailing Address - Street 1:709 KNIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-1943
Mailing Address - Country:US
Mailing Address - Phone:912-283-2311
Mailing Address - Fax:912-283-8204
Practice Address - Street 1:709 KNIGHT AVE
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-1943
Practice Address - Country:US
Practice Address - Phone:912-283-2311
Practice Address - Fax:912-283-8204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00151665CMedicaid
GA11BDRNHMedicare UPIN