Basic Information
| Provider Information | |||||||||
| NPI: | 1831190461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATEL | ||||||||
| FirstName: | RENUKA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 SPRING ARBOR RD STE 102 | ||||||||
| Address2: | PO BOX 905 | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492033895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177832612 | ||||||||
| FaxNumber: | 5177835991 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 N EAST AVE | ||||||||
| Address2: | IMAGING DEPARTMENT | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177832612 | ||||||||
| FaxNumber: | 5177835991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2005 | ||||||||
| LastUpdateDate: | 11/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301044604 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4301044604 | 01 | MI | STATE OF MICHIGAN MEDICAL LICENSE | OTHER | 4383939 | 05 | MI | MEDICAID | 3003802611 | 01 | MI | BCBS OF MI | OTHER | 300129519 | 01 | RAILROAD MEDICARE | OTHER |