Provider Demographics
NPI:1780767145
Name:LARRY L PACK MD PC
Entity type:Organization
Organization Name:LARRY L PACK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-750-5800
Mailing Address - Street 1:9362 WARWICK MDWS
Mailing Address - Street 2:PO BOX 590
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-9552
Mailing Address - Country:US
Mailing Address - Phone:810-750-5800
Mailing Address - Fax:
Practice Address - Street 1:2420 OWEN RD
Practice Address - Street 2:STE C
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3417
Practice Address - Country:US
Practice Address - Phone:810-750-5800
Practice Address - Fax:810-750-5809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035400207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4940460Medicaid
MI6307760001Medicare NSC
MIB42902Medicare UPIN
MI4940460Medicaid