Basic Information
| Provider Information | |||||||||
| NPI: | 1447903760 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLLER | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | RAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458041500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5673714418 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 N VANDEMARK RD | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453653567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374928080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2022 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | OH | Y |
ID Information
| ID | Type | State | Issuer | Description | 568946544 | 01 | OH | BCBS | OTHER | 5874 | 01 | OH | HEALTH PARTNERS | OTHER | 236 | 05 | DC | MEDICAID |