Healthcare Provider Details

I. General information

NPI: 1275198913
Provider Name (Legal Business Name): RENEW FAMILY DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 AIRPORT ROAD W
FORT PAYNE AL
35968
US

IV. Provider business mailing address

212 AIRPORT RD W
FORT PAYNE AL
35968-3335
US

V. Phone/Fax

Practice location:
  • Phone: 256-979-1250
  • Fax: 256-979-1251
Mailing address:
  • Phone: 256-979-1250
  • Fax: 256-979-1251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PAM MASON
Title or Position: MANAGER
Credential:
Phone: 256-867-0851