Basic Information
| Provider Information | |||||||||
| NPI: | 1841229127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENICH | ||||||||
| FirstName: | MICHAELA | ||||||||
| MiddleName: | E. | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 417 E STATESVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281152590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046633063 | ||||||||
| FaxNumber: | 7046634873 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 E STATESVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281152590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046633063 | ||||||||
| FaxNumber: | 7046634873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 98-01460 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 891187G | 05 | NC | MEDICAID |