Healthcare Provider Details

I. General information

NPI: 1629356944
Provider Name (Legal Business Name): RODRIGUEZ MEDICAL GROUP, PA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15190 SW 136TH STREET SUITE 15
MIAMI FL
33196-2604
US

IV. Provider business mailing address

15190 SW 136TH STREET SUITE 15
MIAMI FL
33196-2604
US

V. Phone/Fax

Practice location:
  • Phone: 305-964-7689
  • Fax: 305-964-7989
Mailing address:
  • Phone: 305-964-7689
  • Fax: 305-964-7989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME104034
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9243349
License Number StateFL

VIII. Authorized Official

Name: MRS. INES RODRIGUEZ
Title or Position: PRESIDENT
Credential: ARNP
Phone: 305-964-7689