=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902984966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R ANDREW PACKARD MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 10/03/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 785 OHIO AVE STE 1F
-----------------------------------------------------
City | CLARKSDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38614-6213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-627-2027
-----------------------------------------------------
Fax | 662-627-3424
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 785 OHIO AVE STE 1F
-----------------------------------------------------
City | CLARKSDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38614-6213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-627-2027
-----------------------------------------------------
Fax | 662-627-3424
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RICHARD ANDREW PACKARD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 662-624-2027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 19744
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------