1114955259 NPI number — DR. NEIL A ROACH MD

Table of content: DR. NEIL A ROACH MD (NPI 1114955259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114955259 NPI number — DR. NEIL A ROACH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROACH
Provider First Name:
NEIL
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114955259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 WHITE HORSE PIKE
Provider Second Line Business Mailing Address:
SUITE 9, HEIGHTS IMAGING CENTER
Provider Business Mailing Address City Name:
HADDON HEIGHTS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08035-1299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-546-1177
Provider Business Mailing Address Fax Number:
856-546-0666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 WHITE HORSE PIKE
Provider Second Line Business Practice Location Address:
STE 9
Provider Business Practice Location Address City Name:
HADDON HEIGHTS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08035-1299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-546-1177
Provider Business Practice Location Address Fax Number:
856-546-0666
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MD052730L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 25MA05227300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0014666080020 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0716985000 . This is a "IBC KHPE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001466608 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00390756 . This is a "RRMC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P00403104 . This is a "RRMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: PA7584 . This is a "HEALTHNET" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 231955165 . This is a "AETNA USHC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001466608 . This is a "AMERICHOICE OF PA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 231955165 . This is a "INTERGROUP SERVICES" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 6185703 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 034628 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 367605 . This is a "PHCS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: MD052730L . This is a "HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 30035147 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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