Provider Demographics
NPI:1083646244
Name:PACKER, MARVIN S (MD)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:S
Last Name:PACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:
Practice Address - Street 1:291 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-3628
Practice Address - Country:US
Practice Address - Phone:617-541-6520
Practice Address - Fax:617-541-6444
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA47794207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0014950OtherNEIGHBORHOOD HEALTH
MAM539OtherHARARD PILGRIM
MA047794OtherTUFTS
MA3179061Medicaid
MAJ30278OtherBLUE CROSS
MA3179061Medicaid
MA0014950OtherNEIGHBORHOOD HEALTH