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General NPI Number Information
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NPI Number | 1619263407
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Entity Type | Organization
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Legal Business Name | RENEWAL DERMATOLOGY PLLC
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Dates
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Enumeration Date | 06/21/2011
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Last Update Date | 06/21/2011
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Provider Practice Location Address
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Address Line | 7512 GARDNER PARK DR
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City | GAINESVILLE
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State | VA
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Zip | 20155-3414
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Country | US
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Telephone | 703-753-9860
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Fax | 703-753-9863
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Provider Business Mailing Address
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Address Line | 7512 GARDNER PARK DR
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City | GAINESVILLE
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State | VA
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Zip | 20155-3414
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Country | US
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Telephone | 703-753-9860
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Fax | 703-753-9863
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Authorized Official
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Title or Position | PRESIDENT
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Name | JOANNE GUTLIPH
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Credential | MD
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Telephone | 571-261-2885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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