Provider Demographics
NPI:1659335578
Name:ROMAN, ALAN MARSHALL (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:MARSHALL
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 1:2320 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2426
Mailing Address - Country:US
Mailing Address - Phone:708-388-5500
Mailing Address - Fax:708-388-5672
Practice Address - Street 1:2320 HIGH ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2426
Practice Address - Country:US
Practice Address - Phone:708-388-5500
Practice Address - Fax:708-388-5672
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060612208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL020036557OtherRAILROAD MEDICARE
IL036060612Medicaid
IL652970Medicare PIN
IL020036557Medicare PIN
ILD14385Medicare UPIN