Healthcare Provider Details

I. General information

NPI: 1942594288
Provider Name (Legal Business Name): MARIA C RENNA MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 HAZARD AVE STE 9
ENFIELD CT
06082-4584
US

IV. Provider business mailing address

151 HAZARD AVE. SUITE 9
ENFIELD CT
06082-4588
US

V. Phone/Fax

Practice location:
  • Phone: 860-634-3821
  • Fax:
Mailing address:
  • Phone: 860-634-3821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number044363
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number044363
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number044363
License Number StateCT

VIII. Authorized Official

Name: MARIA C RENNA
Title or Position: OWNER
Credential: MD
Phone: 860-634-3821