MEDICARE: PAUL RENN IV

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	101YP2500X	Professional Counselor	CW019392	PA

General Provider Information

NPI Number	:	1720490030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL RENN IV

Provider Business Mailing Address
First Line	:	5201 HAVERFORD AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139-1401
Country	:	US
Telephone Number	:	215-471-2761
Fax Number	:

Provider Business Practice Location Address
First Line	:	2310 CHRISTOPHER COLUMBUS BLVD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-4206
Country	:	US
Telephone Number	:	215-867-7098
Fax Number	:	267-288-0389

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

Provider Enumeration Date	:	05/21/2014
Last Update Date	:	09/14/2023

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