Basic Information
| Provider Information | |||||||||
| NPI: | 1750339917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROQUE | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 791372 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212791372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016088375 | ||||||||
| FaxNumber: | 3016083979 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 OLD GEORGETOWN RD | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208141422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018963100 | ||||||||
| FaxNumber: | 3018962393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 05/12/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | D0061569 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 040143800 | 05 | DC | MEDICAID | 64460401 | 01 | MD | CAREFIRST BCBS | OTHER | 415096100 | 05 | MD | MEDICAID | 19460029 | 01 | DC | CAREFIRST BCBS | OTHER | 405306100 | 05 | MD | MEDICAID |