Provider Demographics
NPI:1164423398
Name:RENNA, CARMEN MARIA (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:MARIA
Last Name:RENNA
Suffix:
Gender:F
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:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:95 MADISON AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6092
Practice Address - Country:US
Practice Address - Phone:973-829-9998
Practice Address - Fax:973-829-9991
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41692207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1484508Medicaid
NJ098414BMHMedicare ID - Type Unspecified
NJ1484508Medicaid