Provider Demographics
NPI:1629012950
Name:ROLLER, KEITH A (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:ROLLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:4135 BOARDMAN CANFIELD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9803
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:8401 MARKET ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6725
Practice Address - Country:US
Practice Address - Phone:330-286-5330
Practice Address - Fax:330-286-5396
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058177207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2600242Medicaid
OHH011682OtherMEDICARE PTAN
OHP01200681OtherMEDICARE RAILROAD
10896526OtherCAQH
PA1028247410001Medicaid
OH000000811586OtherANTHEM BCBS