Provider Demographics
NPI:1053386151
Name:ROACH, KYLE V (MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:V
Last Name:ROACH
Suffix:
Gender:M
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:PO BOX 3549
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-0549
Mailing Address - Country:US
Mailing Address - Phone:423-698-3309
Mailing Address - Fax:423-624-6355
Practice Address - Street 1:2341 MCCALLIE AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3239
Practice Address - Country:US
Practice Address - Phone:423-698-3309
Practice Address - Fax:423-624-6355
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD34252207L00000X
GAMD45115207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3152236OtherBCBS
TN4347082OtherBC BS OF TN
TN3852604Medicaid
GA05BDHDVMedicare ID - Type Unspecified
H15753Medicare UPIN
TN3852605Medicare ID - Type Unspecified
TN3852604Medicaid