Basic Information
| Provider Information | |||||||||
| NPI: | 1124065628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DWAIHY | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4201 SAINT ANTOINE ST STE 5A | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137453320 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 07/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301076024 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0H208910 | 01 | MI | BLUE CROSS | OTHER |