Healthcare Provider Details

I. General information

NPI: 1619903317
Provider Name (Legal Business Name): RENEE C LASSILA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENEE C PALECEK MD

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 11/27/2023
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 EAST CENTRE AVE
PORTAGE MI
49002
US

IV. Provider business mailing address

5943 STADIUM DR STE 3
KALAMAZOO MI
49009-3016
US

V. Phone/Fax

Practice location:
  • Phone: 269-286-7050
  • Fax: 269-286-7051
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301065740
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: