1700821907 NPI number — RICARDO A ROA MD

Table of content: RICARDO A ROA MD (NPI 1700821907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700821907 NPI number — RICARDO A ROA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROA
Provider First Name:
RICARDO
Provider Middle Name:
A
Provider Name Prefix Text:
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:
1700821907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 JACKSON PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLIPOLIS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-886-9370
Provider Business Mailing Address Fax Number:
740-886-9374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
96 TOWNSHIP ROAD 369 STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROCTORVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45669-9133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-886-9370
Provider Business Practice Location Address Fax Number:
740-886-9374
Provider Enumeration Date:
06/19/2006

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: 207Y00000X , with the licence number:  17624 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: 35-07-8877-R , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000222804 . This is a "OH MEDICAID UNISON" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00420122 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1044883 . This is a "BWC" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1700821907 . This is a "MOUTAIN STATE BC/BS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 310917085172 . This is a "OH MEDICAID CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0954356 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0100708000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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