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NPI Code Detail

MEDICARE: MR. ANDREW MICHAEL RENNER ATC

MEDICARE: MR. ANDREW MICHAEL RENNER ATC
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
12255A2300XAthletic TrainerIL

General Provider Information

NPI Number : 1801857347
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. ANDREW MICHAEL RENNER ATC
Provider Business Mailing Address
First Line : 608 E 7TH ST
Second Line : APT B
City : ALTON
State : IL
Zip : 62002-3614
Country : US
Telephone Number : 618-791-3592
Fax Number :
Provider Business Practice Location Address
First Line : 1 MEMORIAL DR
Second Line :
City : ALTON
State : IL
Zip : 62002-6722
Country : US
Telephone Number : 618-463-7529
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/31/2006
Last Update Date : 07/08/2007

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