MEDICARE: RENAISSANCE PRIMARY CARE AND WELLNESS GROUP LLC

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
1	207Q00000X	Family Medicine Physician	D0060109	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	75XBLF	OTHER	MD	MD BLUE SHIELD
3	33760001	OTHER	MD	BLUE CHOICE

General Provider Information

NPI Number	:	1609097112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE PRIMARY CARE AND WELLNESS GROUP LLC

Provider Business Mailing Address
First Line	:	5500 KNOLL NORTH DR
Second Line	:	SUITE 250
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2209
Country	:	US
Telephone Number	:	410-772-8001
Fax Number	:	410-772-8004

Provider Business Practice Location Address
First Line	:	5500 KNOLL NORTH DR
Second Line	:	SUITE 250
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2209
Country	:	US
Telephone Number	:	410-772-8001
Fax Number	:	410-772-8004

Authorized Official
Title or Position	:	OWNER PHYSICIAN
Name	:	LINDIWE F GREENWOOD
Credential	:	MD
Telephone Number	:	410-772-8001

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	05/13/2008

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