Provider Demographics
NPI:1376511048
Name:ROMAN, EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:ROMAN
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 1:1009 BROAD ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-2509
Mailing Address - Country:US
Mailing Address - Phone:570-368-8389
Mailing Address - Fax:570-368-8391
Practice Address - Street 1:1009 BROAD ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-2509
Practice Address - Country:US
Practice Address - Phone:570-368-8389
Practice Address - Fax:570-368-8391
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD063687L207Q00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA804291OtherFIRST PRIORITY HEALTH
PA969730OtherHIGHMARK BLUE SHIELD
PA2378143OtherUNITEDHEALTHCARE
PA0016591210002Medicaid
PA897668OtherAETNA
PA50054359OtherCAPITAL BLUE CROSS
PAG56772OtherHEALTHAMERICA
PA2378143OtherUNITEDHEALTHCARE
PA0016591210002Medicaid
PA250008656Medicare PIN