MEDICARE: RENAISSANCE MEDICAL CENTER CORP

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	261Q00000X	Clinic/Center	ME125313	FL
2	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1437691169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENAISSANCE MEDICAL CENTER CORP

Provider Business Mailing Address
First Line	:	3832 W HUMPHREY ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-1955
Country	:	US
Telephone Number	:	813-440-4420
Fax Number	:	813-502-0290

Provider Business Practice Location Address
First Line	:	3832 W HUMPHREY ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-1955
Country	:	US
Telephone Number	:	813-440-4420
Fax Number	:	813-502-0290

Authorized Official
Title or Position	:	MD/OWNER
Name	:	AMILCAR M LOMINCHAR
Credential	:	MD
Telephone Number	:	813-440-4420

Provider Enumeration Date	:	11/11/2016
Last Update Date	:	06/05/2023

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