Provider Demographics
NPI:1912117912
Name:RODRIGUEZ-FRIAS, EDMUNDO ALEJANDRO (MD)
Entity Type:Individual
Prefix:
First Name:EDMUNDO
Middle Name:ALEJANDRO
Last Name:RODRIGUEZ-FRIAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062
Mailing Address - Country:US
Mailing Address - Phone:618-462-3200
Mailing Address - Fax:618-463-5003
Practice Address - Street 1:6812 STATE ROUTE 162
Practice Address - Street 2:SUITE 204
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062
Practice Address - Country:US
Practice Address - Phone:618-391-5070
Practice Address - Fax:618-288-1872
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45630207RG0100X
IL036.120237208M00000X
390200000X
IL036-120237207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP1-0022674OtherINSTITUTIONAL PERMIT