Basic Information
| Provider Information | |||||||||
| NPI: | 1568890556 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENAISSANCE GASTROENTEROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6139 | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785026139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563622171 | ||||||||
| FaxNumber: | 9563623614 | ||||||||
| Practice Location | |||||||||
| Address1: | 5501 S MCCOLL RD | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785399152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563622171 | ||||||||
| FaxNumber: | 9563622132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2013 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | ADA | ||||||||
| AuthorizedOfficialMiddleName: | X | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9563622171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.