Healthcare Provider Details

I. General information

NPI: 1710085535
Provider Name (Legal Business Name): RHODORA A SY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RHODORA A REBADIO MD

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S LOCUST ST
MANTENO IL
60950-1656
US

IV. Provider business mailing address

501 S LOCUST ST
MANTENO IL
60950-1654
US

V. Phone/Fax

Practice location:
  • Phone: 815-468-6737
  • Fax: 815-468-2648
Mailing address:
  • Phone: 815-468-6737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036095020
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: