Provider Demographics
NPI:1245206929
Name:ROESCH, THOMAS T (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:T
Last Name:ROESCH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 OLD LANCASTER RD STE 210
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3118
Mailing Address - Country:US
Mailing Address - Phone:610-527-1600
Mailing Address - Fax:610-527-0824
Practice Address - Street 1:830 OLD LANCASTER RD STE 210
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010
Practice Address - Country:US
Practice Address - Phone:610-527-1600
Practice Address - Fax:610-527-0824
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002926L363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232359401OtherMAIN LINE HEALTHCARE
PA232359401OtherMAIN LINE HEALTHCARE
Q54325Medicare UPIN