=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063680114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAQUEL RODRIGUEZ MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2008
-----------------------------------------------------
Last Update Date | 02/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 US HIGHWAY 1 SUITE 204
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-1612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-589-0300
-----------------------------------------------------
Fax | 772-589-4550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 US HIGHWAY 1 SUITE 204
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-1612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-589-0300
-----------------------------------------------------
Fax | 772-589-4550
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/ OWNER
-----------------------------------------------------
Name | EILEEN FERMIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 772-589-0300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | ME 94980
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------