Provider Demographics
NPI:1992005599
Name:ROACH, PHILIP M
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:M
Last Name:ROACH
Suffix:
Gender:M
Credentials:
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 1090
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-6190
Mailing Address - Country:US
Mailing Address - Phone:203-709-3117
Mailing Address - Fax:203-709-8625
Practice Address - Street 1:100 GRAND ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-2016
Practice Address - Country:US
Practice Address - Phone:860-224-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant