Healthcare Provider Details

I. General information

NPI: 1962769059
Provider Name (Legal Business Name): LUKE B ROLLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E BROADWAY AVE
BISMARCK ND
58501-4520
US

IV. Provider business mailing address

900 E BROADWAY AVE
BISMARCK ND
58501-4520
US

V. Phone/Fax

Practice location:
  • Phone: 701-530-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number14508
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: