Provider Demographics
NPI:1487659827
Name:RENUCCI, JOHN DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DAVID
Last Name:RENUCCI
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Gender:M
Credentials:MD
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Mailing Address - Street 1:220 LYON ST NW
Mailing Address - Street 2:STE 700
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2210
Mailing Address - Country:US
Mailing Address - Phone:616-451-4500
Mailing Address - Fax:616-451-9077
Practice Address - Street 1:220 LYON ST NW
Practice Address - Street 2:STE 700
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2210
Practice Address - Country:US
Practice Address - Phone:616-451-4500
Practice Address - Fax:616-451-9077
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MI4301079486208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4403942Medicaid
MI16082011Medicare ID - Type Unspecified
MI4403942Medicaid