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NPI Code Detail

MEDICARE: DR. RENAE ELLEN BOMAR EDD, ATC, SCAT

MEDICARE: DR. RENAE ELLEN BOMAR EDD, ATC, SCAT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer36001019AIN

General Provider Information

NPI Number : 1538125554
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. RENAE ELLEN BOMAR EDD, ATC, SCAT
Provider Business Mailing Address
First Line : 365 BERTRAM RD
Second Line :
City : SUMMERVILLE
State : SC
Zip : 29485-8393
Country : US
Telephone Number : 812-878-0923
Fax Number :
Provider Business Practice Location Address
First Line : 9200 UNIVERSITY BLVD
Second Line :
City : NORTH CHARLESTON
State : SC
Zip : 29406-9121
Country : US
Telephone Number : 812-878-0923
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/26/2006
Last Update Date : 04/24/2023

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