Basic Information
| Provider Information | |||||||||
| NPI: | 1770680407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RENNERT | ||||||||
| FirstName: | ERIC | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 490 RIDGE RD E | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146211229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859222500 | ||||||||
| FaxNumber: | 5859222664 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 RIDGE RD E | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146211229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859222500 | ||||||||
| FaxNumber: | 5859222664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 07/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 096435 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | P010096435 | 01 | EXCELLUS | OTHER | 00448068 | 05 | NY | MEDICAID |