1164648135 NPI number — GEORGE L. RODRIGUEZ, M.D., P.C.

Table of content: MELISSA DOWNS WOMBWELL-TWERSKY (NPI 1689328460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164648135 NPI number — GEORGE L. RODRIGUEZ, M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGE L. RODRIGUEZ, M.D., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
UNIVERSITY DYNAMIC MRI
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164648135
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1938 S COLUMBUS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19148-2802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-462-1500
Provider Business Mailing Address Fax Number:
215-462-2010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1938 S COLUMBUS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19148-2802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-462-1500
Provider Business Practice Location Address Fax Number:
215-462-2010
Provider Enumeration Date:
04/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BAMBA
Authorized Official First Name:
ELLEN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
215-425-1500

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 045575900 . This is a "INDEPENDENCE BLUE CROSS/PERSONAL CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 626086 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".