Provider Demographics
NPI:1649411760
Name:GEORGE L. RODRIGUEZ, M.D., P.C.
Entity Type:Organization
Organization Name:GEORGE L. RODRIGUEZ, M.D., P.C.
Other - Org Name:ADVANCED DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
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 1:1000 EASTON RD
Practice Address - Street 2:SUITE 290
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-2918
Practice Address - Country:US
Practice Address - Phone:215-576-0150
Practice Address - Fax:215-576-5132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD 045274E207R00000X
207R00000X, 208100000X, 2085R0202X, 261QM1200X
PAMD 036647E208100000X
NY131553-1 - NY2085R0202X
NY155494-1 - NY2085R0202X
PAMD 039238E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA626086OtherHIGHMARK BLUE SHIELD
PA0455759000OtherINDEPENDENCE BLUE CROSS
PA0455759000OtherINDEPENDENCE BLUE CROSS