Healthcare Provider Details

I. General information

NPI: 1346205705
Provider Name (Legal Business Name): CARL JOSEPH RENNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 05/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 BOULEVARD STE 2
HASBROUCK HEIGHTS NJ
07604-1319
US

IV. Provider business mailing address

288 BOULEVARD STE 2
HASBROUCK HEIGHTS NJ
07604-1319
US

V. Phone/Fax

Practice location:
  • Phone: 201-288-6781
  • Fax: 201-288-2734
Mailing address:
  • Phone: 201-288-6781
  • Fax: 201-288-2734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA03936900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: