Healthcare Provider Details

I. General information

NPI: 1689713638
Provider Name (Legal Business Name): RENAISSANCE MEDICAL GROUP,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 EASTERN AVE STE B3
FAIRMOUNT HEIGHTS MD
20743-1677
US

IV. Provider business mailing address

PO BOX 2966
HYATTSVILLE MD
20784-0966
US

V. Phone/Fax

Practice location:
  • Phone: 301-925-2255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMD

VIII. Authorized Official

Name: ANDREA L SYPHAX
Title or Position: ADMINISTRATOR
Credential:
Phone: 301-925-2255