Provider Demographics
NPI:1720383714
Name:RRG MEDICAL PRACTICE, PC
Entity Type:Organization
Organization Name:RRG MEDICAL PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-505-0030
Mailing Address - Street 1:9001A ROOSEVELT AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7938
Mailing Address - Country:US
Mailing Address - Phone:718-505-0030
Mailing Address - Fax:718-505-0032
Practice Address - Street 1:3736 90TH ST FL 1
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7830
Practice Address - Country:US
Practice Address - Phone:718-505-0030
Practice Address - Fax:718-505-0032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02461109Medicaid
NY02461109Medicaid