Provider Demographics
NPI:1508849852
Name:ROBERTS, GLENN A (DO)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CHERRY HOSPITAL
Mailing Address - Street 2:1401 WEST ASH STREET
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-1078
Mailing Address - Country:US
Mailing Address - Phone:919-731-3206
Mailing Address - Fax:919-731-3785
Practice Address - Street 1:CHERRY HOSPITAL
Practice Address - Street 2:1401 WEST ASH STREET
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-1078
Practice Address - Country:US
Practice Address - Phone:919-731-3206
Practice Address - Fax:919-731-3785
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009937180Medicaid
AL000098808Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
C32481Medicare UPIN