Provider Demographics
NPI:1013016849
Name:PACK, CURTIS BRENT (DO)
Entity Type:Individual
Prefix:
First Name:CURTIS
Middle Name:BRENT
Last Name:PACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9816
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-757-3252
Practice Address - Street 1:503 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:ELEANOR
Practice Address - State:WV
Practice Address - Zip Code:25070
Practice Address - Country:US
Practice Address - Phone:304-586-0001
Practice Address - Fax:304-586-0079
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV550737600OtherCOMMERICAL INSURANCE
WV001721667OtherBCBS
WA550737600OtherAETNA
OH0245176Medicaid
WV0046893000Medicaid
WV385750OtherFEDERAL BLACK LUNG
WVPA0821091Medicare PIN
WV385750OtherFEDERAL BLACK LUNG
OH0245176Medicaid
WV001721667OtherBCBS
WV0046893000Medicaid
WV2033281Medicare PIN