Basic Information
| Provider Information | |||||||||
| NPI: | 1295944239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PACK | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | JON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3565 MOMENTUM PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164599404 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 LAFAYETTE AVE SE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164599404 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301086174 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 036-125552 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1295944239 | 05 | MI | MEDICAID |