Provider Demographics
NPI:1679572317
Name:PACKER, ROBERT B (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:PACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 MERCY DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708
Mailing Address - Country:US
Mailing Address - Phone:330-489-1454
Mailing Address - Fax:330-430-6913
Practice Address - Street 1:1330 MERCY DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708
Practice Address - Country:US
Practice Address - Phone:330-489-1454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH28167208D00000X
OH35-028167207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0168983Medicaid
OHH090900Medicare PIN
3643220Medicare PIN
OH0168983Medicaid
PA036432200Medicare ID - Type Unspecified