1942260260 NPI number — R ANDREW PACKARD MD

Table of content: R ANDREW PACKARD MD (NPI 1942260260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942260260 NPI number — R ANDREW PACKARD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PACKARD
Provider First Name:
R
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942260260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 KEY HAVEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEY WEST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33040-6212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-532-8687
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 12TH ST STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEY WEST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33040-3001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-294-3458
Provider Business Practice Location Address Fax Number:
305-294-8432
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  ME132264 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C04536 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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