Healthcare Provider Details

I. General information

NPI: 1699980706
Provider Name (Legal Business Name): GEORGE L RODRIGUEZ MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2487 GRANT AVENUE
PHILADELPHIA PA
19114
US

IV. Provider business mailing address

841 E ALLEGHENY AVE
PHILADELPHIA PA
19134-2401
US

V. Phone/Fax

Practice location:
  • Phone: 215-464-0150
  • Fax: 215-464-0174
Mailing address:
  • Phone: 215-425-1500
  • Fax: 215-425-1659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD 045274E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD 036647E
License Number StatePA

VIII. Authorized Official

Name: ELLEN C BAMBA
Title or Position: OFFICE MANAGER
Credential:
Phone: 215-425-1500