Basic Information
| Provider Information | |||||||||
| NPI: | 1023066222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUAN | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2830 VICTORY PKWY | ||||||||
| Address2: | STE 310 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452063700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453444 | ||||||||
| FaxNumber: | 5132453449 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 PIEDMONT AVE | ||||||||
| Address2: | STE 6000 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452194231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134757880 | ||||||||
| FaxNumber: | 5134757327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-046436 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110111852 | 01 | OH | RAIL ROAD MEDICARE | OTHER | 64773947 | 05 | KY | MEDICAID | 0537146 | 05 | OH | MEDICAID | 200070040 | 05 | IN | MEDICAID | 4047838 | 05 | TN | MEDICAID |