Basic Information
Provider Information | |||||||||
NPI: | 1578579678 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RENZI | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT | ||||||||
Address2: | PO BOX 7291 | ||||||||
City: | LEWISTON | ||||||||
State: | ME | ||||||||
PostalCode: | 042437291 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077778560 | ||||||||
FaxNumber: | 2077778800 | ||||||||
Practice Location | |||||||||
Address1: | 100 KENYON AVE | ||||||||
Address2: |   | ||||||||
City: | WAKEFIELD | ||||||||
State: | RI | ||||||||
PostalCode: | 028794299 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4017828000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 10/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD18266 | ME | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207P00000X | MD07004 | RI | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | RR07053 | 05 | RI |   | MEDICAID | 1578579678 | 01 | RI | NPI | OTHER | 939025129 | 01 | RI | RI MEDICARE GROUP NUMBER | OTHER |