Healthcare Provider Details

I. General information

NPI: 1184855223
Provider Name (Legal Business Name): TIANBO REN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 COLUMBIA 100 PKWY STE 100
COLUMBIA MD
21045-2169
US

IV. Provider business mailing address

10373A REISTERSTOWN ROAD ATTN: CREDENTIALING DEPARTMENT
OWINGS MILLS MD
21117-3617
US

V. Phone/Fax

Practice location:
  • Phone: 410-298-0454
  • Fax: 301-694-2606
Mailing address:
  • Phone: 443-548-7595
  • Fax: 410-356-4180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD0079305
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: