Provider Demographics
NPI:1710228986
Name:PACKER, KYLE ANDREW
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ANDREW
Last Name:PACKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 22ND ST S STE 1000
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-2881
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3400 HIGHWAY 78 E STE 316
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8951
Practice Address - Country:US
Practice Address - Phone:205-385-7860
Practice Address - Fax:205-385-7861
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2019-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.2054208600000X
MDH85396208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery