Healthcare Provider Details

I. General information

NPI: 1255402301
Provider Name (Legal Business Name): BRUCE L ROACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2006
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BURDICK EXPY E
MINOT ND
58701-4768
US

IV. Provider business mailing address

PO BOX 5010
MINOT ND
58702-5010
US

V. Phone/Fax

Practice location:
  • Phone: 701-857-7383
  • Fax: 701-857-7342
Mailing address:
  • Phone: 701-418-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9524
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: