Basic Information
Provider Information | |||||||||
NPI: | 1447221817 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROAN | ||||||||
FirstName: | RONALD | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1012 IRVING RD | ||||||||
Address2: |   | ||||||||
City: | HOMEWOOD | ||||||||
State: | AL | ||||||||
PostalCode: | 352093428 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2054270691 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 608 STONE AVENUE | ||||||||
Address2: |   | ||||||||
City: | TALLADEGA | ||||||||
State: | AL | ||||||||
PostalCode: | 356102217 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059795882 | ||||||||
FaxNumber: | 2059791248 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2006 | ||||||||
LastUpdateDate: | 06/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 24176 | AL | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LC0200X | 24176 | AL | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207PE0004X | 24176 | AL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 2083A0100X | 24176 | AL | N |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Aerospace Medicine | 208D00000X | 24176 | AL | N |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 009910247 | 05 | AL |   | MEDICAID | 128722 | 05 | AL |   | MEDICAID | 009910246 | 05 | AL |   | MEDICAID | 009910243 | 05 | AL |   | MEDICAID | 511-15720 | 01 | AL | BC BS OF AL | OTHER | 009910248 | 05 | AL |   | MEDICAID |