=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215142260
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ELIZABETH RODES M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 UNIVERSITY BLVD
-----------------------------------------------------
City | BEAVERCREEK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45324-2640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-245-7200
-----------------------------------------------------
Fax | 866-644-1883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 431 MONTERAY AVE
-----------------------------------------------------
City | OAKWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45419-2654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-604-9136
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 88956
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------