Healthcare Provider Details

I. General information

NPI: 1841876588
Provider Name (Legal Business Name): FRITZLAINE C. ROCHE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEW HOSP PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

1 BARNES JEW HOSP PLZ
SAINT LOUIS MO
63110-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1935
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2021020661
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9410577
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2021020661
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2022019693
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: