Provider Demographics
NPI:1275198913
Name:RENEW FAMILY DERMATOLOGY LLC
Entity Type:Organization
Organization Name:RENEW FAMILY DERMATOLOGY LLC
Other - Org Name:RENEW FAMILY DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-867-0851
Mailing Address - Street 1:1403 OLD WATER WORKS RD SW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968
Mailing Address - Country:US
Mailing Address - Phone:256-979-1250
Mailing Address - Fax:256-979-1251
Practice Address - Street 1:1403 OLD WATER WORKS RD SW
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968-3596
Practice Address - Country:US
Practice Address - Phone:256-979-1250
Practice Address - Fax:256-979-1251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL236456Medicaid