Basic Information
Provider Information | |||||||||
NPI: | 1386602662 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RENNER | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 140 OSIGIAN BLVD | ||||||||
Address2: | BLDG 300 | ||||||||
City: | WARNER ROBINS | ||||||||
State: | GA | ||||||||
PostalCode: | 310887879 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4783290291 | ||||||||
FaxNumber: | 4783333609 | ||||||||
Practice Location | |||||||||
Address1: | 140 OSIGIAN BLVD | ||||||||
Address2: | BLDG 300 | ||||||||
City: | WARNER ROBINS | ||||||||
State: | GA | ||||||||
PostalCode: | 310887879 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4783290291 | ||||||||
FaxNumber: | 4783333609 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2006 | ||||||||
LastUpdateDate: | 02/25/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 038594 | GA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 080178726 | 05 | GA |   | MEDICAID | GRP4178 | 01 | GA | MEDICARE GROUP NUMBER | OTHER | 080178726 | 01 | GA | RAIL ROAD MEDICARE NUMBER | OTHER |