Healthcare Provider Details

I. General information

NPI: 1720287071
Provider Name (Legal Business Name): RENAISSANCE FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 CHARLESTOWN RD SUITE 2
NEW ALBANY IN
47150
US

IV. Provider business mailing address

2580 CHARLESTOWN RD SUITE 2
NEW ALBANY IN
47150
US

V. Phone/Fax

Practice location:
  • Phone: 812-948-9500
  • Fax: 812-948-9600
Mailing address:
  • Phone: 812-948-9500
  • Fax: 812-948-9600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01036882A
License Number StateIN

VIII. Authorized Official

Name: DR. ANNA M. FISHER
Title or Position: MANAGER/OWNER
Credential: MD
Phone: 812-948-9500