Provider Demographics
NPI:1376769372
Name:BASKERVILLE, RENEE E (MD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:E
Last Name:BASKERVILLE
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 141
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042
Mailing Address - Country:US
Mailing Address - Phone:973-677-1551
Mailing Address - Fax:973-509-2658
Practice Address - Street 1:90 WASHINGTON ST
Practice Address - Street 2:SUITE 209
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017
Practice Address - Country:US
Practice Address - Phone:973-677-1551
Practice Address - Fax:973-509-2658
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA504892080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2016907Medicaid