Healthcare Provider Details

I. General information

NPI: 1396934287
Provider Name (Legal Business Name): A B ROA MEDICAL CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 US HIGHWAY 27 S
LAKE PLACID FL
33852-7904
US

IV. Provider business mailing address

PO BOX 2829
LAKE PLACID FL
33862-2829
US

V. Phone/Fax

Practice location:
  • Phone: 863-465-6200
  • Fax: 863-465-9217
Mailing address:
  • Phone: 863-465-6200
  • Fax: 863-465-9217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME0042772
License Number StateFL

VIII. Authorized Official

Name: DR. ANTONIO B ROA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 863-465-6200