Basic Information
| Provider Information | |||||||||
| NPI: | 1245265321 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDMUND J ROACHE MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MULLIN STREET | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157858591 | ||||||||
| FaxNumber: | 3157858591 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MULLIN STREET | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157858591 | ||||||||
| FaxNumber: | 3157858591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROACHE | ||||||||
| AuthorizedOfficialFirstName: | EDMUND | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3157824475 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 153941 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00772743 | 05 | NY | MEDICAID |