Basic Information
| Provider Information | |||||||||
| NPI: | 1376511048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMAN | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1009 BROAD ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MONTOURSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177542509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703688389 | ||||||||
| FaxNumber: | 5703688391 | ||||||||
| Practice Location | |||||||||
| Address1: | 1009 BROAD ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MONTOURSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177542509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703688389 | ||||||||
| FaxNumber: | 5703688391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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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 | 207Q00000X | MD063687L | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 208100000X | MD063687L | PA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 804291 | 01 | PA | FIRST PRIORITY HEALTH | OTHER | 969730 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 2378143 | 01 | PA | UNITEDHEALTHCARE | OTHER | 0016591210002 | 05 | PA | MEDICAID | 897668 | 01 | PA | AETNA | OTHER | 50054359 | 01 | PA | CAPITAL BLUE CROSS | OTHER | G56772 | 01 | PA | HEALTHAMERICA | OTHER |