Provider Demographics
NPI:1497719249
Name:PACKER, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:PACKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 EASTON ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-1009
Mailing Address - Country:US
Mailing Address - Phone:267-537-3300
Mailing Address - Fax:267-537-2939
Practice Address - Street 1:2603 EASTON ROAD
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1009
Practice Address - Country:US
Practice Address - Phone:267-537-3300
Practice Address - Fax:267-537-2939
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 025180E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA597586OtherTPI GROUP MEDICARE ID
PA1007278000OtherTPI GROUP MEDICAID ID
PACD4829OtherTPI RAILROAD MEDICARE GROUP
PACD4829OtherTPI RAILROAD MEDICARE GROUP