Provider Demographics
NPI:1285700377
Name:REXBURG FAMILY MEDICAL CENTER, PLLC
Entity type:Organization
Organization Name:REXBURG FAMILY MEDICAL CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:PACKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-356-9231
Mailing Address - Street 1:1 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2024
Mailing Address - Country:US
Mailing Address - Phone:208-356-9231
Mailing Address - Fax:208-356-9141
Practice Address - Street 1:1 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2024
Practice Address - Country:US
Practice Address - Phone:208-356-9231
Practice Address - Fax:208-356-9141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1377619Medicare ID - Type Unspecified