MEDICARE: GLENN ROUTHOUSKA 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	J1031	TX

General Provider Information

NPI Number	:	1821091703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN ROUTHOUSKA D.O.

Provider Business Mailing Address
First Line	:	PO BOX 846098
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-6098
Country	:	US
Telephone Number	:	903-324-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 S LOOP 256
Second Line	:
City	:	PALESTINE
State	:	TX
Zip	:	75801-6901
Country	:	US
Telephone Number	:	903-723-0330
Fax Number	:

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/16/2020

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