Provider Demographics
NPI:1376626507
Name:ROACH, DONALD MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:MICHAEL
Last Name:ROACH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5238
Mailing Address - Fax:740-441-8058
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5238
Practice Address - Fax:740-441-8058
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.9133-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
001917039OtherMOUNTAIN STATE BCBS
OH2701446Medicaid
WV3810007256Medicaid
000000497528OtherANTHEM BCBS
OHP00356781OtherRR MEDICARE
OH8238562Medicare PIN