Provider Demographics
NPI:1811196629
Name:PACKARD MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:PACKARD MEDICAL GROUP, P.A.
Other - Org Name:PINELAND MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:PACKARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-787-3520
Mailing Address - Street 1:PO BOX 1948
Mailing Address - Street 2:
Mailing Address - City:HEMPHILL
Mailing Address - State:TX
Mailing Address - Zip Code:75948-1948
Mailing Address - Country:US
Mailing Address - Phone:409-584-2411
Mailing Address - Fax:409-584-3884
Practice Address - Street 1:105 TIMBERLAND HWY
Practice Address - Street 2:
Practice Address - City:PINELAND
Practice Address - State:TX
Practice Address - Zip Code:75968
Practice Address - Country:US
Practice Address - Phone:409-584-2411
Practice Address - Fax:409-584-3884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00X870Medicare UPIN