Healthcare Provider Details

I. General information

NPI: 1083864219
Provider Name (Legal Business Name): RENOVO MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 03/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 N CAMPUS DR SUITE 500
GARDEN CITY KS
67846-6329
US

IV. Provider business mailing address

816 N CAMPUS DR SUITE 500
GARDEN CITY KS
67846-6329
US

V. Phone/Fax

Practice location:
  • Phone: 620-805-5162
  • Fax: 620-805-5183
Mailing address:
  • Phone: 620-805-5162
  • Fax: 620-805-5183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number0416265
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1500265
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number45404
License Number StateKS
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberKS0434389
License Number StateKS

VIII. Authorized Official

Name: PROF. JOEL T ERSKIN
Title or Position: CEO/PHYSICIAN ASSISTANT
Credential: SCD PA-C
Phone: 620-805-5162