Provider Demographics
NPI:1154683357
Name:ROACH, BRENT ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:ALLEN
Last Name:ROACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5129 DIXIE HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-1727
Mailing Address - Country:US
Mailing Address - Phone:502-447-8786
Mailing Address - Fax:502-447-8623
Practice Address - Street 1:5129 DIXIE HWY STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216
Practice Address - Country:US
Practice Address - Phone:502-447-8786
Practice Address - Fax:502-447-8623
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD00000511862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100478060Medicaid