Provider Demographics
NPI:1851177570
Name:BACKPACK MEDICAL GROUP PC
Entity Type:Organization
Organization Name:BACKPACK MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DUKE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUKTANONCHAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-306-4394
Mailing Address - Street 1:2023 W GROVE DR
Mailing Address - Street 2:
Mailing Address - City:GIBSONIA
Mailing Address - State:PA
Mailing Address - Zip Code:15044-6059
Mailing Address - Country:US
Mailing Address - Phone:630-306-4394
Mailing Address - Fax:
Practice Address - Street 1:6655 SANTA BARBARA RD UNIT 8574
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-7523
Practice Address - Country:US
Practice Address - Phone:866-968-6342
Practice Address - Fax:855-615-2876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty