Healthcare Provider Details

I. General information

NPI: 1487610564
Provider Name (Legal Business Name): RICHARD ALLEN ROLLER MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 E LEE ST SUITE C
ENTERPRISE AL
36330-2368
US

IV. Provider business mailing address

805 E LEE ST SUITE C
ENTERPRISE AL
36330-2368
US

V. Phone/Fax

Practice location:
  • Phone: 334-348-8818
  • Fax: 334-393-8773
Mailing address:
  • Phone: 334-348-8818
  • Fax: 334-393-8773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number29971
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number29971
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number29971
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: