Provider Demographics
NPI:1265572515
Name:EDMOND E PACK MD PC
Entity type:Organization
Organization Name:EDMOND E PACK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:E
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-734-1202
Mailing Address - Street 1:3201 S MARYLAND PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2441
Mailing Address - Country:US
Mailing Address - Phone:702-734-1202
Mailing Address - Fax:702-734-8320
Practice Address - Street 1:3201 S MARYLAND PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2441
Practice Address - Country:US
Practice Address - Phone:702-734-1202
Practice Address - Fax:702-734-8320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9904207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVH52449Medicare UPIN
NVV104083Medicare PIN