Healthcare Provider Details

I. General information

NPI: 1184297954
Provider Name (Legal Business Name): RENEW REHABILITATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24725 W 12 MILE RD STE 260
SOUTHFIELD MI
48034-8310
US

IV. Provider business mailing address

24725 W 12 MILE RD STE 260
SOUTHFIELD MI
48034-8310
US

V. Phone/Fax

Practice location:
  • Phone: 248-382-8052
  • Fax:
Mailing address:
  • Phone: 248-382-8052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MORGAN GLAZER
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 248-550-4800