Provider Demographics
NPI:1538243134
Name:ROLAND, AUGUSTINE (MD)
Entity type:Individual
Prefix:MR
First Name:AUGUSTINE
Middle Name:
Last Name:ROLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 COPPERFIELD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432
Mailing Address - Country:US
Mailing Address - Phone:815-727-4434
Mailing Address - Fax:815-727-4498
Practice Address - Street 1:1301 COPPERFIELD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432
Practice Address - Country:US
Practice Address - Phone:815-727-4434
Practice Address - Fax:815-727-4498
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036046641208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
036046641OtherIRA
C38265Medicare UPIN
742380Medicare ID - Type Unspecified