Provider Demographics
NPI:1487629739
Name:PACK, BILLIE CANDICE (DO)
Entity Type:Individual
Prefix:DR
First Name:BILLIE
Middle Name:CANDICE
Last Name:PACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CRESTMONT CT.
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-9480
Mailing Address - Country:US
Mailing Address - Phone:412-657-5245
Mailing Address - Fax:
Practice Address - Street 1:4230 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1826
Practice Address - Country:US
Practice Address - Phone:919-477-9805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012220174400000X
TXN2226208100000X
NC2011-01899208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001894130Medicaid
TX613851OtherMEDICARE PTAN
NCNC47140281OtherMEDICARE PTAN
PA001894130Medicaid
TX613851OtherMEDICARE PTAN