MEDICARE: DR. GLEN A ROUNTREE MD

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	208800000X	Urology Physician	D5189	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144222100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLEN A ROUNTREE MD

Provider Business Mailing Address
First Line	:	5002 COWHORN CREEK RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-9766
Country	:	US
Telephone Number	:	903-614-3000
Fax Number	:	903-614-3525

Provider Business Practice Location Address
First Line	:	1902 MOORES LN
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-4610
Country	:	US
Telephone Number	:	903-792-7515
Fax Number	:	903-791-8645

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

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	04/20/2011

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