Provider Demographics
NPI:1619946282
Name:ROACH, MONA SI (MD)
Entity Type:Individual
Prefix:DR
First Name:MONA
Middle Name:SI
Last Name:ROACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:1285 NININGER RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-1086
Practice Address - Country:US
Practice Address - Phone:651-480-4200
Practice Address - Fax:651-480-4306
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080004370OtherRAILROAD MEDICARE
MN11R00R0OtherBLUE CROSS
MN01-02679OtherMEDICA
MN764806OtherAMERICAS PPO
MN66-02253OtherMEDICA URGENT CARE
WI32397200Medicaid
MN833224000Medicaid
MNHP23823OtherHEALTHPARTNERS
MN120927OtherUCARE MINNESOTA
MN32397200OtherGROUP HEALTH EAU CLAIRE
MNNA9141014618OtherPREFERRED ONE
MN764806OtherAMERICAS PPO
MN11R00R0OtherBLUE CROSS