1982606851 NPI number — RENAISSANCE MEDICAL LLC

Table of content: (NPI 1982606851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982606851 NPI number — RENAISSANCE MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENAISSANCE MEDICAL LLC
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:
1982606851
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1380 W 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40741-1615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-878-0453
Provider Business Mailing Address Fax Number:
606-878-1862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4530 BISHOP LN
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40218-4561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-961-8560
Provider Business Practice Location Address Fax Number:
606-878-1862
Provider Enumeration Date:
08/11/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRAHAM
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
606-878-0453

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  HME00021 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: MG0190 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 164438 . This is a "IN STATE DEPT HLTH CSH" identifier . This identifiers is of the category "OTHER".
  • Identifier: S864 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2196098 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 040021100 . This is a "FEDERAL BLACK LUNG PROGRA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 119010 . This is a "BCBS MI ABP PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: C82008 . This is a "CHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110110 . This is a "AMERICAN BENEFIT PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 228579 . This is a "GHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 006895400 . This is a "US DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 26404V2111 . This is a "AHDS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7100165610 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: C82003 . This is a "CHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000070422 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7100166520 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 822271 . This is a "BCBS PENN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1079739 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 1171574 . This is a "CUMBERLAND HEALTHCARE" identifier . This identifiers is of the category "OTHER".