Provider Demographics
NPI:1346216116
Name:RENSHAW, BRYAN RAY
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:RAY
Last Name:RENSHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 FAIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-8009
Mailing Address - Country:US
Mailing Address - Phone:501-758-1300
Mailing Address - Fax:501-758-1316
Practice Address - Street 1:4801 FAIRWAY AVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-8009
Practice Address - Country:US
Practice Address - Phone:501-758-1300
Practice Address - Fax:501-758-1316
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2221225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155038742Medicaid
AR5U797OtherBCBS
AR5G468OtherMEDICARE GROUP
AR5G239OtherBCBS GROUP
AR5G239OtherBCBS GROUP
AR155038742Medicaid