Provider Demographics
NPI:1871823245
Name:FLINT R PACKER DO PC
Entity Type:Organization
Organization Name:FLINT R PACKER DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FLINT
Authorized Official - Middle Name:R
Authorized Official - Last Name:PACKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-552-7700
Mailing Address - Street 1:3614 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7573
Mailing Address - Country:US
Mailing Address - Phone:208-552-7700
Mailing Address - Fax:208-552-1786
Practice Address - Street 1:3614 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7573
Practice Address - Country:US
Practice Address - Phone:208-552-7700
Practice Address - Fax:208-552-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1302064Medicare PIN