Healthcare Provider Details

I. General information

NPI: 1417948282
Provider Name (Legal Business Name): ROBERT M PACKER III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 KNIGHT AVE
WAYCROSS GA
31501-1943
US

IV. Provider business mailing address

711 KNIGHT AVE
WAYCROSS GA
31501-1943
US

V. Phone/Fax

Practice location:
  • Phone: 912-283-9423
  • Fax: 912-283-8204
Mailing address:
  • Phone: 912-283-9423
  • Fax: 912-283-8204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number18716
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number18716
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: