Healthcare Provider Details

I. General information

NPI: 1013722602
Provider Name (Legal Business Name): JAMES LOUIS ROUNDTREE III LAT, ATC, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 02/11/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2419 STATE AVE
CORAOPOLIS PA
15108-2233
US

IV. Provider business mailing address

334 ACADEMY ST
CARNEGIE PA
15106-2782
US

V. Phone/Fax

Practice location:
  • Phone: 724-980-4233
  • Fax:
Mailing address:
  • Phone: 724-980-4233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberRT007029
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: