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General NPI Number Information
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NPI Number | 1316195159
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Entity Type | Individual
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Provider Name | PAUL BRYAN ROACH M.D., F.A.C.S.
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Gender | Male
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Dates
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Enumeration Date | 09/05/2008
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Last Update Date | 12/23/2024
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Provider Practice Location Address
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Address Line | 2160 S 1ST AVE
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City | MAYWOOD
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State | IL
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Zip | 60153-3328
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Country | US
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Telephone | 708-216-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 221 NORTHVIEW DR
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City | CHESAPEAKE
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State | VA
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Zip | 23322-4041
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Country | US
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Telephone | 757-953-2544
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 036113684
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 2086X0206X
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Taxonomy Name | Surgical Oncology Physician
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License Number | 56692
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 2086X0206X
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Taxonomy Name | Surgical Oncology Physician
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License Number | 036113684
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License Number State | IL
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