Basic Information
| Provider Information | |||||||||
| NPI: | 1063644326 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROMAIN | ||||||||
| FirstName: | MCLEAN | ||||||||
| MiddleName: | JOHNSON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 E LAUREL RD | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407418601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6063307825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 SAINT JOSEPH LN | ||||||||
| Address2: | |||||||||
| City: | LONDON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407418345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063306000 | ||||||||
| FaxNumber: | 6063306536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2009 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT196138 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 45488 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100224800 | 05 | KY | MEDICAID |