MEDICARE: DR. CRAIG RICHARD KAI PACK D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QX0100X	Occupational Medicine Clinic/Center	O-1118	ID
2	207Q00000X	Family Medicine Physician	O-1118	ID

General Provider Information

NPI Number	:	1346239951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRAIG RICHARD KAI PACK D.O.

Provider Business Mailing Address
First Line	:	1955 FREMONT AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-1510
Country	:	US
Telephone Number	:	208-526-2195
Fax Number	:	208-526-8631

Provider Business Practice Location Address
First Line	:	1955 FREMONT AVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83402-1510
Country	:	US
Telephone Number	:	208-526-2195
Fax Number	:	208-526-8631

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	05/12/2026

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