Provider Demographics
NPI:1619978830
Name:ROACH, JAMES P (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:ROACH
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:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:KY
Mailing Address - Zip Code:40347-0277
Mailing Address - Country:US
Mailing Address - Phone:859-846-4445
Mailing Address - Fax:859-846-4761
Practice Address - Street 1:129 S WINTER ST
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:KY
Practice Address - Zip Code:40347-1015
Practice Address - Country:US
Practice Address - Phone:859-846-4445
Practice Address - Fax:859-846-4761
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64213218Medicaid
C72406Medicare UPIN
0583701Medicare ID - Type Unspecified