Provider Demographics
NPI: | 1851344279 |
---|---|
Name: | LAROCHE, ROGER R (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | ROGER |
Middle Name: | R |
Last Name: | LAROCHE |
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: | 116 INTERSTATE PKWY |
Mailing Address - Street 2: | |
Mailing Address - City: | BRADFORD |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 16701-1036 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 814-368-3123 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 777 RAYMOND AVE |
Practice Address - Street 2: | |
Practice Address - City: | SAINT PAUL |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55114-1522 |
Practice Address - Country: | US |
Practice Address - Phone: | 651-447-3755 |
Practice Address - Fax: | 651-444-8923 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-05-18 |
Last Update Date: | 2022-12-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
PA | MD046764L | 2084P0800X |
MN | 32177 | 2084A0401X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084A0401X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | 0012987900001 | Medicaid | |
PA | 068601D0V | Medicare PIN | |
PA | E86576 | Medicare UPIN |