Provider Demographics
NPI:1275511032
Name:RENNER, ANDREW IHOR (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:IHOR
Last Name:RENNER
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 1:2701 W ALAMEDA AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4402
Mailing Address - Country:US
Mailing Address - Phone:818-843-1497
Mailing Address - Fax:818-843-5283
Practice Address - Street 1:2701 W ALAMEDA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4402
Practice Address - Country:US
Practice Address - Phone:818-843-1497
Practice Address - Fax:818-843-5283
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42417208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G424170Medicaid
CA00G424170Medicaid
A92337Medicare UPIN