Healthcare Provider Details

I. General information

NPI: 1629034392
Provider Name (Legal Business Name): SCOTT EARL RENSHAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD UH 3005
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 130 PROVIDER ENROLLMENT
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-2167
  • Fax: 317-944-2305
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01057319A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: