Provider Demographics
NPI:1437122231
Name:RENVYLE, TAD T (MD)
Entity Type:Individual
Prefix:
First Name:TAD
Middle Name:T
Last Name:RENVYLE
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 1:703 RIVERWAY PL
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6745
Mailing Address - Country:US
Mailing Address - Phone:603-627-1661
Mailing Address - Fax:603-669-6944
Practice Address - Street 1:703 RIVERWAY PL
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6745
Practice Address - Country:US
Practice Address - Phone:603-627-1661
Practice Address - Fax:603-669-6944
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD206162085R0202X
NH115732085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30202047Medicaid
NH30202047Medicaid
NHRE6700Medicare ID - Type Unspecified