Healthcare Provider Details

I. General information

NPI: 1851344279
Provider Name (Legal Business Name): ROGER R LAROCHE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 RAYMOND AVE
SAINT PAUL MN
55114-1522
US

IV. Provider business mailing address

116 INTERSTATE PKWY
BRADFORD PA
16701-1036
US

V. Phone/Fax

Practice location:
  • Phone: 651-447-3755
  • Fax: 651-444-8923
Mailing address:
  • Phone: 814-368-3123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD046764L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number32177
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: