1275403362 NPI number — RENADIN MIEMANANG SIAGAT PHARMD, PHD, BCRCP

Table of content: RENADIN MIEMANANG SIAGAT PHARMD, PHD, BCRCP (NPI 1275403362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275403362 NPI number — RENADIN MIEMANANG SIAGAT PHARMD, PHD, BCRCP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIAGAT
Provider First Name:
RENADIN
Provider Middle Name:
MIEMANANG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD, PHD, BCRCP
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:
1275403362
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4806 WILLOW STEAD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLNEY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20832-2083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-338-0685
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4806 WILLOW STEAD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLNEY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20832-2083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-338-0685
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2025

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: 1835P0018X , with the licence number:  26640 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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