Healthcare Provider Details

I. General information

NPI: 1730400136
Provider Name (Legal Business Name): ALEXIS MARCO RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2010
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 MAPLEWOOD AVE
RONCEVERTE WV
24970-8016
US

IV. Provider business mailing address

973 RIVERWATCH DR
VILLA HILLS KY
41017-3769
US

V. Phone/Fax

Practice location:
  • Phone: 304-793-2220
  • Fax: 304-793-2277
Mailing address:
  • Phone: 860-208-5169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number48607
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2019020860
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.127031
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number28433
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: