MEDICARE: ROLAND ROY LARTER 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	207Q00000X	Family Medicine Physician	17741	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17741	OTHER	MN	MD LICENSE

General Provider Information

NPI Number	:	1235167636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROLAND ROY LARTER M.D.

Provider Business Mailing Address
First Line	:	1010 S BIRCH AVE
Second Line	:	P.O. BOX 700
City	:	HALLOCK
State	:	MN
Zip	:	56728-4215
Country	:	US
Telephone Number	:	218-843-2868
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 S BIRCH AVE
Second Line	:
City	:	HALLOCK
State	:	MN
Zip	:	56728-4215
Country	:	US
Telephone Number	:	218-843-2868
Fax Number	:

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	07/08/2007

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