Provider Demographics
NPI:1508832973
Name:PACKER, MICHAEL G (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
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 1:200 BOWMAN DR
Mailing Address - Street 2:STE E360
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-9623
Mailing Address - Country:US
Mailing Address - Phone:856-751-7880
Mailing Address - Fax:
Practice Address - Street 1:200 BOWMAN DR
Practice Address - Street 2:STE E360
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9623
Practice Address - Country:US
Practice Address - Phone:856-751-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06445800208800000X
PAMD031083E208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7062109Medicaid
PA1605990Medicaid
F02098Medicare UPIN