Provider Demographics
NPI:1629284096
Name:GEORGE L RODRIGUEZ MD PC
Entity Type:Organization
Organization Name:GEORGE L RODRIGUEZ MD PC
Other - Org Name:INJURY REHABILITATION CENTERS OF PENNSYLVANIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-425-1500
Mailing Address - Street 1:841 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-2401
Mailing Address - Country:US
Mailing Address - Phone:215-425-1500
Mailing Address - Fax:215-425-1659
Practice Address - Street 1:1938 S COLUMBUS BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2802
Practice Address - Country:US
Practice Address - Phone:215-462-1500
Practice Address - Fax:215-462-2010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 045274E207R00000X
PAMD 036647E208100000X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA045575900OtherINDEPENDENCE BLUE CROSS/PERSONAL CHOICE
PA626086OtherHIGHMARK BLUE SHIELD
PA045575900OtherINDEPENDENCE BLUE CROSS/PERSONAL CHOICE