1215921614 NPI number — DR. GEORGE SCOTT RENTON D.O.

Table of content: DR. GEORGE SCOTT RENTON D.O. (NPI 1215921614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215921614 NPI number — DR. GEORGE SCOTT RENTON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RENTON
Provider First Name:
GEORGE
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1215921614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
957 BROOKHAVEN CT
Provider Second Line Business Mailing Address:
BUILDING E STE 3 & 4
Provider Business Mailing Address City Name:
MUSKEGON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49442-3890
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-777-5906
Provider Business Mailing Address Fax Number:
231-773-8904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
957 BROOOKHAVEN CT
Provider Second Line Business Practice Location Address:
BUILDING E SUITE 3 & 4
Provider Business Practice Location Address City Name:
MUSKEGON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49442-3886
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-777-5906
Provider Business Practice Location Address Fax Number:
231-773-8904
Provider Enumeration Date:
08/31/2005

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: 207R00000X , with the licence number:  5101007424 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2720950-11 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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