Provider Demographics
NPI:1114998309
Name:RENNICK, RONALD LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:LESLIE
Last Name:RENNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1232 UNIVERSITY OF OREGON
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-1205
Mailing Address - Country:US
Mailing Address - Phone:541-346-0565
Mailing Address - Fax:541-346-2748
Practice Address - Street 1:1232 UNIVERSITY OF OREGON
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1232
Practice Address - Country:US
Practice Address - Phone:541-346-0565
Practice Address - Fax:541-346-2748
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10449261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR217562Medicaid
OR930026495OtherRAILROAD MEDICARE
OR093ZGBFMFMedicare ID - Type Unspecified
OR217562Medicaid