MEDICARE: GLENN RIEGO PUERTOLLANO 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	207R00000X	Internal Medicine Physician	38924	KY

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	:	1679544381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN RIEGO PUERTOLLANO MD

Provider Business Mailing Address
First Line	:	PO BOX 2748
Second Line	:	RED RIVER HEALTH CARE
City	:	PIKEVILLE
State	:	KY
Zip	:	41502-2748
Country	:	US
Telephone Number	:	606-432-3221
Fax Number	:	606-437-0438

Provider Business Practice Location Address
First Line	:	321C EAST COLLEGE AVE
Second Line	:	RED RIVER HEALTH CARE
City	:	STANTON
State	:	KY
Zip	:	40380
Country	:	US
Telephone Number	:	606-663-9797
Fax Number	:	606-663-9470

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

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	07/08/2007

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