Healthcare Provider Details

I. General information

NPI: 1396117610
Provider Name (Legal Business Name): RENAISSANCE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 10/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 EASTERN AVE 2ND FLOOR
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: 301-925-2020
Mailing address:
  • Phone: 301-925-2255
  • Fax: 301-925-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number104804
License Number StateMD

VIII. Authorized Official

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