MEDICARE: GLEN T PEARSON 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	2084P0804X	Child & Adolescent Psychiatry Physician	D8594	TX

General Provider Information

NPI Number	:	1851574362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN T PEARSON M.D.

Provider Business Mailing Address
First Line	:	3303 LEE PKWY
Second Line	:	220
City	:	DALLAS
State	:	TX
Zip	:	75219-5108
Country	:	US
Telephone Number	:	214-522-5120
Fax Number	:	214-522-5488

Provider Business Practice Location Address
First Line	:	3303 LEE PKWY
Second Line	:	220
City	:	DALLAS
State	:	TX
Zip	:	75219-5108
Country	:	US
Telephone Number	:	214-522-5120
Fax Number	:	214-522-5488

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

Provider Enumeration Date	:	12/07/2007
Last Update Date	:	12/11/2007

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