Basic Information
| Provider Information | |||||||||
| NPI: | 1679578751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PACK | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 457 | ||||||||
| Address2: | 5 E ALVON ROAD, SUITE 7 | ||||||||
| City: | WHITE SULPHUR SPRINGS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249862373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045365030 | ||||||||
| FaxNumber: | 3045365031 | ||||||||
| Practice Location | |||||||||
| Address1: | JACKSON RIVER ORTHOPEDICS | ||||||||
| Address2: | 1 ARH LANE, STE 102 | ||||||||
| City: | LOW MOOR | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408626777 | ||||||||
| FaxNumber: | 5408639167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 10/15/2011 | ||||||||
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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 | 0102201406 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200026 | 01 | LUNG | OTHER | 541839718104 | 01 | VA | BS MOUNTAIN STATE | OTHER | 465499 | 01 | WV | ANTHEM | OTHER | 541839718 | 01 | C&O | OTHER | 7194496 | 01 | AETNA | OTHER | 213824 | 01 | CARELINK | OTHER | 3003781000 | 05 | WV | MEDICAID | 213824 | 01 | SOUTHERN HEALTH | OTHER | 5431529 | 01 | CCN | OTHER | 465498 | 01 | VA | ANTHEM | OTHER | 006409806 | 05 | VA | MEDICAID | 54183971800 | 01 | WV | WV WORKERS COMPENSATION | OTHER | 541839718103 | 01 | WV | BS MOUNTAIN STATE | OTHER |