Basic Information
| Provider Information | |||||||||
| NPI: | 1003496720 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOUNT | ||||||||
| FirstName: | ROMAN | ||||||||
| MiddleName: | PEELE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 19475 OLD JETTON RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CORNELIUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280316591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841775 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 19475 OLD JETTON RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CORNELIUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280316591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841775 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2021 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | BLOU-LA8994 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.