Provider Demographics
NPI:1427204965
Name:RENAKER-JANSEN, ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:RENAKER-JANSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W LINCOLN ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1900
Mailing Address - Country:US
Mailing Address - Phone:618-277-7400
Mailing Address - Fax:618-277-7422
Practice Address - Street 1:340 W LINCOLN ST
Practice Address - Street 2:SUITE 500
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1900
Practice Address - Country:US
Practice Address - Phone:618-277-7400
Practice Address - Fax:618-277-7422
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017812208600000X
IL036141213208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery