Basic Information
| Provider Information | |||||||||
| NPI: | 1215142260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODES | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 431 MONTERAY AVE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454192654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376049136 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 725 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453242640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372457200 | ||||||||
| FaxNumber: | 8666441883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2007 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 88956 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 311248312 | 01 | OH | PRACTICE TAX ID # | OTHER | FR0117033 | 01 | OH | DEA | OTHER | 2766378 | 05 | OH | MEDICAID | 311352092 | 01 | OH | PRACTICE TAX ID # | OTHER |