Healthcare Provider Details

I. General information

NPI: 1205443504
Provider Name (Legal Business Name): RENOVIS HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26206 W 12 MILE RD STE 302
SOUTHFIELD MI
48034-8501
US

IV. Provider business mailing address

29155 NORTHWESTERN HWY # 515
SOUTHFIELD MI
48034-1011
US

V. Phone/Fax

Practice location:
  • Phone: 424-303-0544
  • Fax:
Mailing address:
  • Phone: 800-960-1463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: OLISAELOKA DALLAH
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 248-470-7318