1962597021 NPI number — SHADY GROVE PEDIATRIC ASSOCIATES

Table of content: DR. STEPHEN FRANK RENNER DC (NPI 1912073180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962597021 NPI number — SHADY GROVE PEDIATRIC ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHADY GROVE PEDIATRIC ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1962597021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15215 SHADY GROVE ROAD
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-330-3216
Provider Business Mailing Address Fax Number:
301-330-0026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15215 SHADY GROVE RD
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20850-3235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-330-3216
Provider Business Practice Location Address Fax Number:
301-330-0026
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PLOTSKY
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
301-330-3216

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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