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General NPI Number Information
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NPI Number | 1669424602
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Entity Type | Organization
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Legal Business Name | EDMUND JOSEPH ROACHE, M.D.
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Dates
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Enumeration Date | 05/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 200 MULLIN ST
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City | WATERTOWN
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State | NY
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Zip | 13601-3619
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Country | US
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Telephone | 315-785-8591
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Fax | 315-782-4475
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Provider Business Mailing Address
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Address Line | PO BOX 91
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City | WATERTOWN
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State | NY
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Zip | 13601-0091
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Country | US
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Telephone | 315-782-4207
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Fax | 315-782-8699
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Authorized Official
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Title or Position | OWNER
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Name | EDMUND J ROACHE
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Credential | M.D.
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Telephone | 315-785-8591
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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