MEDICARE: GEORGE L RODRIGUEZ MD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD 045274E	PA
2	208100000X	Physical Medicine & Rehabilitation Physician	MD 036647E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	045575900	OTHER	PA	INDEPENDENCE BLUE CROSS/PERSONAL CHOICE

General Provider Information

NPI Number	:	1699980706
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGE L RODRIGUEZ MD PC

Provider Business Mailing Address
First Line	:	841 E ALLEGHENY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19134-2401
Country	:	US
Telephone Number	:	215-425-1500
Fax Number	:	215-425-1659

Provider Business Practice Location Address
First Line	:	2487 GRANT AVENUE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114
Country	:	US
Telephone Number	:	215-464-0150
Fax Number	:	215-464-0174

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ELLEN C BAMBA
Credential	:
Telephone Number	:	215-425-1500

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	06/27/2008

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