1922015049 NPI number — GARY A. ROACH, O.D., P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922015049 NPI number — GARY A. ROACH, O.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARY A. ROACH, O.D., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1922015049
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
404 E CENTER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28115-2544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-663-3924
Provider Business Mailing Address Fax Number:
704-663-7057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 E CENTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28115-2544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-663-3924
Provider Business Practice Location Address Fax Number:
704-663-7057
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROACH
Authorized Official First Name:
GARY
Authorized Official Middle Name:
ARTHUR
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
704-663-3924

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  863 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 018TF . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DG1209 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2209268 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 15906 . This is a "PARTNERS MEDICARE CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5906031 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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