Healthcare Provider Details

I. General information

NPI: 1013328913
Provider Name (Legal Business Name): TIMOTHY ROACH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNIVERSITY DR
HERSHEY PA
17033-2360
US

IV. Provider business mailing address

500 UNIVERSITY DRIVE MAIL CODE H043; PO BOX 850
HERSHEY PA
17033
US

V. Phone/Fax

Practice location:
  • Phone: 717-531-6039
  • Fax:
Mailing address:
  • Phone: 717-531-6039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number04084
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberOS020426
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: