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General NPI Number Information
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NPI Number | 1922305077
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Entity Type | Organization
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Legal Business Name | FAMILY MEDICINE & SURGERY LLC
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Dates
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Enumeration Date | 02/24/2011
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Last Update Date | 02/24/2011
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Provider Practice Location Address
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Address Line | 3066 MAIN ST
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City | EAST TROY
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State | WI
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Zip | 53120-1148
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Country | US
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Telephone | 262-642-7313
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Fax | 262-642-4251
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Provider Business Mailing Address
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Address Line | 3066 MAIN ST
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City | EAST TROY
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State | WI
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Zip | 53120-1148
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Country | US
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Telephone | 262-642-7313
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Fax | 262-642-4251
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Authorized Official
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Title or Position | SOLE PROPRIETOR
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Name | DR. NEIL JAMES RENNICK
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Credential | D.O.
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Telephone | 262-642-7313
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 26462
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License Number State | WI
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