Healthcare Provider Details

I. General information

NPI: 1154683357
Provider Name (Legal Business Name): BRENT ALLEN ROACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AUDUBON PLAZA DR
LOUISVILLE KY
40217-1318
US

IV. Provider business mailing address

5129 DIXIE HWY STE 100
LOUISVILLE KY
40216-1727
US

V. Phone/Fax

Practice location:
  • Phone: 502-447-8786
  • Fax: 502-447-8623
Mailing address:
  • Phone: 502-447-8786
  • Fax: 502-447-8623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD0000051186
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: