Healthcare Provider Details

I. General information

NPI: 1790769792
Provider Name (Legal Business Name): HENRI RENOM DE LA BAUME MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 FARRELL ROAD DEWITT ARMY COMMUNITY HOSPITAL
FORT BELVOIR VA
22060
US

IV. Provider business mailing address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

V. Phone/Fax

Practice location:
  • Phone: 703-805-0071
  • Fax: 703-805-0189
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberD34498
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01068264A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number01068264A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD34498
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: