Healthcare Provider Details

I. General information

NPI: 1821291303
Provider Name (Legal Business Name): CARL B ROUNTREE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5875 BREMO RD SUITE 303
RICHMOND VA
23226-1934
US

IV. Provider business mailing address

5875 BREMO RD SUITE 303
RICHMOND VA
23226-1934
US

V. Phone/Fax

Practice location:
  • Phone: 804-893-8610
  • Fax: 804-287-7285
Mailing address:
  • Phone: 804-893-8610
  • Fax: 804-287-7285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD431447
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number0101251638
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: