Provider Demographics
NPI:1275510661
Name:PACKER, SCOTT M (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:M
Last Name:PACKER
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:PO BOX 1647
Mailing Address - Street 2:2860 CHANNING WAY SUITE 115
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1647
Mailing Address - Country:US
Mailing Address - Phone:208-535-4130
Mailing Address - Fax:208-535-4125
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-1647
Practice Address - Country:US
Practice Address - Phone:208-535-4130
Practice Address - Fax:208-535-4125
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5990207P00000X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID58180OtherBLUE CROSS
ID3886500Medicaid
ID3886500Medicaid
E96292Medicare UPIN