MEDICARE: RENAISSANCE REHABILITATION ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5601004162	MI
2	225X00000X	Occupational Therapist	5201006390	MI

General Provider Information

NPI Number	:	1053599340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE REHABILITATION ASSOCIATES

Provider Business Mailing Address
First Line	:	4460 SWEET CHERRY LN
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49004-3725
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4460 SWEET CHERRY LN
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49004-3725
Country	:	US
Telephone Number	:	269-377-5594
Fax Number	:	269-344-8991

Authorized Official
Title or Position	:	CEO
Name	:	MR. JOEL M PHILLIPS
Credential	:
Telephone Number	:	269-377-5594

Provider Enumeration Date	:	02/08/2008
Last Update Date	:	02/08/2008

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