Provider Demographics
NPI:1326026790
Name:RENNER, PAUL BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:BRADLEY
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 1:100 FREEMAN DR
Mailing Address - Street 2:
Mailing Address - City:ST PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-3504
Mailing Address - Country:US
Mailing Address - Phone:507-931-7100
Mailing Address - Fax:507-931-7220
Practice Address - Street 1:100 FREEMAN DR
Practice Address - Street 2:
Practice Address - City:ST PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-3504
Practice Address - Country:US
Practice Address - Phone:507-931-7100
Practice Address - Fax:507-931-7220
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN351602084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNE09461Medicare UPIN