=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073603031
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETH ANNE RENZULLI MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 09/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 SLEEPY HOLLOW DR STE 200
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19709-5841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-449-0070
-----------------------------------------------------
Fax | 302-613-7548
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 SLEEPY HOLLOW DRIVE, SUITE 200
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-449-0070
-----------------------------------------------------
Fax | 302-613-7548
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | D0060425
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | C10007078
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------