Provider Demographics
NPI:1104895986
Name:ROACH, KEVIN R (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:ROACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:1285 NININGER RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MN
Practice Address - Zip Code:55033-1086
Practice Address - Country:US
Practice Address - Phone:651-480-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40335208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN020037023OtherRAILROAD MEDICARE
MN02F64ROOtherBLUE CROSS
MN32371200OtherMEDICAID WI
MN66-02258OtherMEDICA URGENT CARE
MN764561OtherAMERICAS PPO
MN942819400OtherGROUP HEALTH EAU CLAIRE
MNNA9141014588OtherPREFERRED ONE
MN120840OtherUCARE MINNESOTA
MNHP23558OtherHEALTH PARTNERS
MN17-00169OtherMEDICA
MN942819400Medicaid
MNNA9141014588OtherPREFERRED ONE
MN942819400Medicaid