Healthcare Provider Details

I. General information

NPI: 1063436897
Provider Name (Legal Business Name): GREGORY C. ROCHE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43494 S. WOODWARD AVE SUITE 101
BLOOMFIELD HILLS MI
48302
US

IV. Provider business mailing address

50 N PERRY ST
PONTIAC MI
48342-2217
US

V. Phone/Fax

Practice location:
  • Phone: 248-338-1110
  • Fax: 248-338-4590
Mailing address:
  • Phone: 248-338-5516
  • Fax: 248-338-5547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number5101007111
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: