Provider Demographics
NPI:1417060740
Name:PACKMAN, BARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:
Last Name:PACKMAN
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 1:9880 BUSTLETON AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19115
Mailing Address - Country:US
Mailing Address - Phone:215-969-2900
Mailing Address - Fax:215-969-1856
Practice Address - Street 1:9880 BUSTLETON AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19115
Practice Address - Country:US
Practice Address - Phone:215-969-2900
Practice Address - Fax:215-969-1856
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD022894E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0053964000OtherBLUE SHIELD
PA0007931240001Medicaid
08278OtherAETNA
0053964000OtherBLUE SHIELD
PA0007931240001Medicaid