Basic Information
| Provider Information | |||||||||
| NPI: | 1417060740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PACKMAN | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9880 BUSTLETON AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159692900 | ||||||||
| FaxNumber: | 2159691856 | ||||||||
| Practice Location | |||||||||
| Address1: | 9880 BUSTLETON AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159692900 | ||||||||
| FaxNumber: | 2159691856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207R00000X | MD022894E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0053964000 | 01 | BLUE SHIELD | OTHER | 0007931240001 | 05 | PA | MEDICAID | 08278 | 01 | AETNA | OTHER |