Healthcare Provider Details

I. General information

NPI: 1760851620
Provider Name (Legal Business Name): AILEEN K ROMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HARRISON AVE YACC 4
BOSTON MA
02118-4001
US

IV. Provider business mailing address

720 HARRISON AVE DOB 503
BOSTON MA
02118-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-2080
  • Fax: 617-414-2090
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number106330
License Number StateZZ
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number265193
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: