Basic Information
| Provider Information | |||||||||
| NPI: | 1619946282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROACH | ||||||||
| FirstName: | MONA | ||||||||
| MiddleName: | S.I. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2925 CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122625000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1285 NININGER RD | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550331086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514804200 | ||||||||
| FaxNumber: | 6514804306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 40336 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080004370 | 01 | MN | RAILROAD MEDICARE | OTHER | 11R00R0 | 01 | MN | BLUE CROSS | OTHER | 01-02679 | 01 | MN | MEDICA | OTHER | 764806 | 01 | MN | AMERICAS PPO | OTHER | 66-02253 | 01 | MN | MEDICA URGENT CARE | OTHER | 32397200 | 05 | WI | MEDICAID | 833224000 | 05 | MN | MEDICAID | HP23823 | 01 | MN | HEALTHPARTNERS | OTHER | 120927 | 01 | MN | UCARE MINNESOTA | OTHER | 32397200 | 01 | MN | GROUP HEALTH EAU CLAIRE | OTHER | NA9141014618 | 01 | MN | PREFERRED ONE | OTHER |