Basic Information
| Provider Information | |||||||||
| NPI: | 1952364192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMAN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1975 HWY 54 W | ||||||||
| Address2: | STE 205 | ||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302694794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785619000 | ||||||||
| FaxNumber: | 7704871232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1975 HIGHWAY 54 W | ||||||||
| Address2: | STE 205 | ||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302694794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785619000 | ||||||||
| FaxNumber: | 7704871232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | POD001026 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 127289526B | 05 | GA | MEDICAID | 202I489463 | 01 | GA | MEDICARE PTAN | OTHER | 127289526C | 05 | GA | MEDICAID | 127289526D | 05 | GA | MEDICAID | 127289526E | 05 | GA | MEDICAID |