Healthcare Provider Details

I. General information

NPI: 1023096781
Provider Name (Legal Business Name): RENEE RAIMONDI DEWEESE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENEE MICHELLE RAIMONDI MD

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SUMMIT CROSSING PLACE STE 106
GASTONIA NC
28054
US

IV. Provider business mailing address

620 SUMMIT CROSSING PL STE 106
GASTONIA NC
28054-2176
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-8021
  • Fax: 704-864-4606
Mailing address:
  • Phone: 704-867-8021
  • Fax: 704-864-4606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number200000394
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number200000394
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: