Provider Demographics
NPI:1780636704
Name:ROACHE, EDMUND J (MD)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:J
Last Name:ROACHE
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 1:200 MULLIN ST
Mailing Address - Street 2:#102
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3619
Mailing Address - Country:US
Mailing Address - Phone:315-782-4475
Mailing Address - Fax:315-785-8591
Practice Address - Street 1:200 MULLIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3619
Practice Address - Country:US
Practice Address - Phone:315-785-8591
Practice Address - Fax:315-782-4475
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00772743Medicaid
RB0385Medicare PIN
39113BMedicare PIN
NY00772743Medicaid