Provider Demographics
NPI:1295725398
Name:ROACH, ROBERT BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BENJAMIN
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 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-8681
Mailing Address - Fax:740-353-7900
Practice Address - Street 1:1805 27TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2686
Practice Address - Country:US
Practice Address - Phone:740-356-8117
Practice Address - Fax:740-353-1214
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY362622085R0202X
WV203952085R0202X
GUMC-1962085R0202X
OH350743422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH300123721OtherRAILROAD MEDICARE
KY000000393352OtherBCBS
OH2071725Medicaid
WV0122863000Medicaid
KY000000199860OtherBCBS
OH300126546OtherRAILROAD MEDICARE
KYP00254967OtherRAILROAD MEDICARE
KY64961188Medicaid
KY64961188Medicaid