Basic Information
| Provider Information | |||||||||
| NPI: | 1518962737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LORIN | ||||||||
| FirstName: | ROMAN | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 POWERHOUSE RD | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | ROSLYN HEIGHTS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115771324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166266366 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115802145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162566000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 210968 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 02143415 | 05 | NY | MEDICAID |