1093822090 NPI number — MARLENE V RODRIGUEZ MD

Table of content: MARLENE V RODRIGUEZ MD (NPI 1093822090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093822090 NPI number — MARLENE V RODRIGUEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODRIGUEZ
Provider First Name:
MARLENE
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093822090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 E. NEW YORK AVE
Provider Second Line Business Mailing Address:
4TH FLOOR - SPG
Provider Business Mailing Address City Name:
SOMERS POINT
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-653-3994
Provider Business Mailing Address Fax Number:
609-926-4311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2605 SHORE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTHFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08225-2136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-365-5300
Provider Business Practice Location Address Fax Number:
609-365-5306
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MA066529 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8364702 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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