MEDICARE: DR. RENEE M KRUSNIAK DO

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	207Q00000X	Family Medicine Physician	5101013855	MI

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

General Provider Information

NPI Number	:	1396847042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RENEE M KRUSNIAK DO

Provider Business Mailing Address
First Line	:	2462 E HILL RD
Second Line	:	STE 1
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-5427
Country	:	US
Telephone Number	:	810-695-1234
Fax Number	:	810-603-3182

Provider Business Practice Location Address
First Line	:	2462 E HILL RD
Second Line	:	SUITE 1
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-5064
Country	:	US
Telephone Number	:	810-695-1234
Fax Number	:	810-603-3182

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

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	11/20/2011

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