Basic Information
| Provider Information | |||||||||
| NPI: | 1942436191 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RENOWN OB GYN GROUP | ||||||||
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| OtherOrganizationName: | RENOWN MEDICAL GROUP WOMEN'S HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 KUENZLI ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759824590 | ||||||||
| FaxNumber: | 7759824595 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 PRINGLE WAY | ||||||||
| Address2: | SUITE 1007 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759826570 | ||||||||
| FaxNumber: | 7759826571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 07/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | AHNER | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7759824404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NV | MEDICAID |