Basic Information
Provider Information | |||||||||
NPI: | 1841411824 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEISS | ||||||||
FirstName: | RENU | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3170 KETTERING BLVD BLDG B | ||||||||
Address2: |   | ||||||||
City: | MORAINE | ||||||||
State: | OH | ||||||||
PostalCode: | 454391924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9379913188 | ||||||||
FaxNumber: | 9372239811 | ||||||||
Practice Location | |||||||||
Address1: | 30 E APPLE ST STE NW3300 | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 454092939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372088394 | ||||||||
FaxNumber: | 3796412780 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2007 | ||||||||
LastUpdateDate: | 03/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01057122A | IN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 01057122A | IN | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | 35.137613 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 201033120 | 05 | IN |   | MEDICAID | P01214653 | 01 | IN | RR MEDICARE PTAN | OTHER | 01057122A | 01 | IN | LICENSE NUMBER | OTHER |