Healthcare Provider Details

I. General information

NPI: 1922685429
Provider Name (Legal Business Name): RENEE MARIE STULLICH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 03/29/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MYERS PARK CLINIC OB/GYN 1350 S. KINGS DR.
CHARLOTTE NC
28207
US

IV. Provider business mailing address

823 S CHURCH ST APT 4307
GREENVILLE SC
29601-4744
US

V. Phone/Fax

Practice location:
  • Phone: 704-446-1544
  • Fax: 704-446-1551
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number302840
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: