MEDICARE: DR. GLEN JOSEPH BOOTH M.D.

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	208D00000X	General Practice Physician	B29991	MN

General Provider Information

NPI Number	:	1083740393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLEN JOSEPH BOOTH M.D.

Provider Business Mailing Address
First Line	:	1089 25TH AVE SE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-2637
Country	:	US
Telephone Number	:	612-379-0212
Fax Number	:

Provider Business Practice Location Address
First Line	:	1089 25TH AVE SE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-2637
Country	:	US
Telephone Number	:	612-379-0212
Fax Number	:

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

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	05/24/2026

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