Provider Demographics
NPI:1124202262
Name:RENAISSANCE WOMENS CENTER, LLC
Entity Type:Organization
Organization Name:RENAISSANCE WOMENS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-887-7313
Mailing Address - Street 1:6111 HARRISON ST
Mailing Address - Street 2:SUITE 255
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-2969
Mailing Address - Country:US
Mailing Address - Phone:773-887-7313
Mailing Address - Fax:
Practice Address - Street 1:6111 HARRISON ST
Practice Address - Street 2:SUITE 255
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2969
Practice Address - Country:US
Practice Address - Phone:773-887-7313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026315A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000084532OtherANTHEM
IN100147650AMedicaid
IN000000084532OtherANTHEM
IN100147650AMedicaid