Healthcare Provider Details

I. General information

NPI: 1376534396
Provider Name (Legal Business Name): GARY T ROOME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

G-3375 S. SAGINAW ST.
BURTON MI
48529
US

IV. Provider business mailing address

225 E 5TH ST SUITE 300
FLINT MI
48502-1641
US

V. Phone/Fax

Practice location:
  • Phone: 810-743-6830
  • Fax: 810-743-7086
Mailing address:
  • Phone: 810-406-4246
  • Fax: 810-424-6029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301045407
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: