MEDICARE: MR. BRYAN RAY RENSHAW

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	225100000X	Physical Therapist	PT 2221	AR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	5G468	OTHER	AR	MEDICARE GROUP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	5U797	OTHER	AR	BCBS
4	5G239	OTHER	AR	BCBS GROUP

General Provider Information

NPI Number	:	1346216116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYAN RAY RENSHAW

Provider Business Mailing Address
First Line	:	4801 FAIRWAY AVE
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-8009
Country	:	US
Telephone Number	:	501-758-1300
Fax Number	:	501-758-1316

Provider Business Practice Location Address
First Line	:	4801 FAIRWAY AVE
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-8009
Country	:	US
Telephone Number	:	501-758-1300
Fax Number	:	501-758-1316

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	08/22/2011

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Directions to “ MR. BRYAN RAY RENSHAW ” Practice Location

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