Provider Demographics
NPI:1407982515
Name:BLOCH, ROMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:
Last Name:BLOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7339
Mailing Address - Fax:616-361-5828
Practice Address - Street 1:5775 WAYZATA BLVD STE 190
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:952-541-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012411222085R0202X
MI43010915212085R0202X
MN635112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology