Healthcare Provider Details

I. General information

NPI: 1528086139
Provider Name (Legal Business Name): JANE E ROACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4439 STATE ROUTE 159 STE G10
CHILLICOTHEE OH
45601-7708
US

IV. Provider business mailing address

4439 STATE ROUTE 159 STE G10
CHILLICOTHEE OH
45601-7708
US

V. Phone/Fax

Practice location:
  • Phone: 740-779-4300
  • Fax: 740-779-4390
Mailing address:
  • Phone: 740-779-4300
  • Fax: 740-779-4390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.044110
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: