Basic Information
| Provider Information | |||||||||
| NPI: | 1437122231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENVYLE | ||||||||
| FirstName: | TAD | ||||||||
| MiddleName: | T | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 703 RIVERWAY PL | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031106745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036271661 | ||||||||
| FaxNumber: | 6036696944 | ||||||||
| Practice Location | |||||||||
| Address1: | 703 RIVERWAY PL | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031106745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036271661 | ||||||||
| FaxNumber: | 6036696944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 11573 | NH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 30202047 | 05 | NH | MEDICAID |