Healthcare Provider Details

I. General information

NPI: 1811234032
Provider Name (Legal Business Name): RENEW MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 UNIVERSITY DR S
FARGO ND
58103-6050
US

IV. Provider business mailing address

2829 UNIVERSITY DR S STE 105
FARGO ND
58103-6050
US

V. Phone/Fax

Practice location:
  • Phone: 701-404-9909
  • Fax: 877-813-3081
Mailing address:
  • Phone: 701-404-9909
  • Fax: 877-813-3081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number44547
License Number StateMN

VIII. Authorized Official

Name: DR. DAVID JEROME HANSON
Title or Position: OWNER
Credential: MD
Phone: 218-770-1006