MEDICARE: GLENN A ROBERTS D.O.

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	DO314	AL

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	:	1508849852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN A ROBERTS D.O.

Provider Business Mailing Address
First Line	:	CHERRY HOSPITAL
Second Line	:	1401 WEST ASH STREET
City	:	GOLDSBORO
State	:	NC
Zip	:	27530-1078
Country	:	US
Telephone Number	:	919-731-3206
Fax Number	:	919-731-3785

Provider Business Practice Location Address
First Line	:	CHERRY HOSPITAL
Second Line	:	1401 WEST ASH STREET
City	:	GOLDSBORO
State	:	NC
Zip	:	27530-1078
Country	:	US
Telephone Number	:	919-731-3206
Fax Number	:	919-731-3785

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

Provider Enumeration Date	:	11/21/2005
Last Update Date	:	10/06/2020

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