Basic Information
| Provider Information | |||||||||
| NPI: | 1295725398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROACH | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | BENJAMIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH ST STE B06 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568681 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1805 27TH ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568117 | ||||||||
| FaxNumber: | 7403531214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 20395 | WV | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 35074342 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 36262 | KY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000393352 | 01 | KY | BCBS | OTHER | 300126546 | 01 | OH | RAILROAD MEDICARE | OTHER | 2071725 | 05 | OH | MEDICAID | 64961188 | 05 | KY | MEDICAID | P00254967 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000199860 | 01 | KY | BCBS | OTHER | 0122863000 | 05 | WV | MEDICAID | 300123721 | 01 | OH | RAILROAD MEDICARE | OTHER |