Provider Demographics
NPI:1023324027
Name:ROGER L ROARK, MD PA
Entity type:Organization
Organization Name:ROGER L ROARK, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-873-2516
Mailing Address - Street 1:555 KITCHINGS DR STE C
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-3576
Mailing Address - Country:US
Mailing Address - Phone:704-873-2516
Mailing Address - Fax:704-873-1431
Practice Address - Street 1:555 KITCHINGS DR STE C
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3576
Practice Address - Country:US
Practice Address - Phone:704-873-2516
Practice Address - Fax:704-873-1431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20190208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC71981OtherBCBS
NC79-71981Medicaid
NC79-71981Medicaid