Healthcare Provider Details

I. General information

NPI: 1164425831
Provider Name (Legal Business Name): JOHN M. ROACH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 BERGER RD
PADUCAH KY
42003-4522
US

IV. Provider business mailing address

242 BERGER RD
PADUCAH KY
42003-4522
US

V. Phone/Fax

Practice location:
  • Phone: 270-366-0960
  • Fax: 271-554-1108
Mailing address:
  • Phone: 270-366-0960
  • Fax: 270-554-1108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number39216
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: