Healthcare Provider Details

I. General information

NPI: 1659344356
Provider Name (Legal Business Name): KENNETH KEENEY RENWICK, JR. MD, MPH, FAAFP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2006
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18880 CHERRY VALLEY BLVD
TUOLUMNE CA
95379-9506
US

IV. Provider business mailing address

18880 CHERRY VALLEY BLVD
TUOLUMNE CA
95379-9506
US

V. Phone/Fax

Practice location:
  • Phone: 209-928-5400
  • Fax: 209-928-5412
Mailing address:
  • Phone: 209-928-5400
  • Fax: 209-928-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG50654
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG50654
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: