Provider Demographics
NPI:1346563285
Name:MICHAEL S. ROATH MD FAPA PC
Entity Type:Organization
Organization Name:MICHAEL S. ROATH MD FAPA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PSYCHIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROATH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-451-6113
Mailing Address - Street 1:8322 TRAFORD LN
Mailing Address - Street 2:SUITE D
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-1668
Mailing Address - Country:US
Mailing Address - Phone:703-451-6113
Mailing Address - Fax:703-866-2430
Practice Address - Street 1:8322 TRAFORD LN
Practice Address - Street 2:SUITE D
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1668
Practice Address - Country:US
Practice Address - Phone:703-451-6113
Practice Address - Fax:703-866-2430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-06
Last Update Date:2010-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101020922261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA178939Medicare PIN
VAB94264Medicare UPIN