Healthcare Provider Details

I. General information

NPI: 1659335578
Provider Name (Legal Business Name): ALAN MARSHALL ROMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 HIGH ST
BLUE ISLAND IL
60406-2426
US

IV. Provider business mailing address

2320 HIGH ST
BLUE ISLAND IL
60406-2426
US

V. Phone/Fax

Practice location:
  • Phone: 708-388-5500
  • Fax: 708-388-5672
Mailing address:
  • Phone: 708-388-5500
  • Fax: 708-388-5672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036060612
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: