1720383714 NPI number — RRG MEDICAL PRACTICE, PC

Table of content: (NPI 1720383714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720383714 NPI number — RRG MEDICAL PRACTICE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RRG MEDICAL PRACTICE, PC
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:
Provider Other Organization Name Type Code:
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:
1720383714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9001A ROOSEVELT AVE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
JACKSON HEIGHTS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11372-7938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-505-0030
Provider Business Mailing Address Fax Number:
718-505-0032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3736 90TH ST FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON HEIGHTS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11372-7830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-505-0030
Provider Business Practice Location Address Fax Number:
718-505-0032
Provider Enumeration Date:
01/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
RAFAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
718-505-0030

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02461109 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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