Provider Demographics
NPI:1477534774
Name:PACK, LARRY L (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:PACK
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 590
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48480-0590
Mailing Address - Country:US
Mailing Address - Phone:810-750-5800
Mailing Address - Fax:810-750-5809
Practice Address - Street 1:2420 OWEN RD
Practice Address - Street 2:STE C
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3417
Practice Address - Country:US
Practice Address - Phone:810-750-5800
Practice Address - Fax:810-750-5809
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035400207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4940460Medicaid
MI4940460Medicaid
MIOP36570Medicare PIN