Provider Demographics
NPI:1326022815
Name:ROACH, MICHAEL BRIAN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRIAN
Last Name:ROACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-782-5110
Mailing Address - Fax:951-274-0403
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2615
Practice Address - Country:US
Practice Address - Phone:951-782-3701
Practice Address - Fax:951-784-3262
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39269207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ31887ZOtherGROUP SITE NUMBER
A47761Medicare UPIN
00G39269Medicare ID - Type Unspecified