Provider Demographics
NPI:1700926771
Name:RODRIGUEZ, CARLOS (PT)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E. MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060
Mailing Address - Country:US
Mailing Address - Phone:773-837-6209
Mailing Address - Fax:
Practice Address - Street 1:2875 W. 19TH STREET
Practice Address - Street 2:ST. ANTHONY HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623
Practice Address - Country:US
Practice Address - Phone:773-484-4150
Practice Address - Fax:773-521-5092
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70014218225100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist