Provider Demographics
NPI:1841331907
Name:ROACH, ALICE JEANNETTE (MD)
Entity type:Individual
Prefix:DR
First Name:ALICE
Middle Name:JEANNETTE
Last Name:ROACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44477 MALTESE FALCON SQ
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-3886
Mailing Address - Country:US
Mailing Address - Phone:703-723-5463
Mailing Address - Fax:703-723-5463
Practice Address - Street 1:44477 MALTESE FALCON SQ
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-3886
Practice Address - Country:US
Practice Address - Phone:703-723-5463
Practice Address - Fax:703-723-5463
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD046855L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA726330Medicare ID - Type Unspecified
PAA41837Medicare UPIN