Healthcare Provider Details

I. General information

NPI: 1124202262
Provider Name (Legal Business Name): RENAISSANCE WOMENS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2007
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 HARRISON ST SUITE 255
MERRILLVILLE IN
46410-2969
US

IV. Provider business mailing address

6111 HARRISON ST SUITE 255
MERRILLVILLE IN
46410-2969
US

V. Phone/Fax

Practice location:
  • Phone: 773-887-7313
  • Fax:
Mailing address:
  • Phone: 773-887-7313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01026315A
License Number StateIN

VIII. Authorized Official

Name: DR. DEBORAH LYNNE MCCULLOUGH
Title or Position: CEO/OWNER
Credential: MD
Phone: 219-887-7313