MEDICARE: GLENN L ROBERTSON 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	207Q00000X	Family Medicine Physician	M-14903	ID
2	207Q00000X	Family Medicine Physician	12808A	WY
3	207Q00000X	Family Medicine Physician	0101246275	VA
4	207Q00000X	Family Medicine Physician	372285-1205	UT

General Provider Information

NPI Number	:	1144281122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN L ROBERTSON MD

Provider Business Mailing Address
First Line	:	PO BOX 5546
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80217-5546
Country	:	US
Telephone Number	:	801-475-3500
Fax Number	:	801-475-3414

Provider Business Practice Location Address
First Line	:	2380 N 400 E STE A
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-1756
Country	:	US
Telephone Number	:	435-554-3240
Fax Number	:	435-554-3241

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

Provider Enumeration Date	:	03/30/2006
Last Update Date	:	01/29/2025

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