MEDICARE: DR. MARY ELLEN RENNA M.D.

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	2080A0000X	Pediatric Adolescent Medicine Physician	171285	NY

General Provider Information

NPI Number	:	1336111780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ELLEN RENNA M.D.

Provider Business Mailing Address
First Line	:	40 CROSSWAYS PARK DR
Second Line	:
City	:	WOODBURY
State	:	NY
Zip	:	11797-2036
Country	:	US
Telephone Number	:	516-677-9628
Fax Number	:	516-677-9623

Provider Business Practice Location Address
First Line	:	40 CROSSWAYS PARK DR
Second Line	:
City	:	WOODBURY
State	:	NY
Zip	:	11797-2036
Country	:	US
Telephone Number	:	516-677-9628
Fax Number	:	516-677-9623

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2006
Last Update Date	:	07/08/2007

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