Provider Demographics
NPI:1508062043
Name:RENNICK, NEIL JAMES (DO)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:JAMES
Last Name:RENNICK
Suffix:
Gender:M
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:PO BOX 45
Mailing Address - Street 2:3066 MAIN ST
Mailing Address - City:EAST TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120-0045
Mailing Address - Country:US
Mailing Address - Phone:262-642-7313
Mailing Address - Fax:262-642-4251
Practice Address - Street 1:3066 MAIN ST # 45
Practice Address - Street 2:
Practice Address - City:EAST TROY
Practice Address - State:WI
Practice Address - Zip Code:53120-1148
Practice Address - Country:US
Practice Address - Phone:262-642-7313
Practice Address - Fax:262-642-4251
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI26462OtherLICENSE NUMBER
WI30100300Medicaid
B56004Medicare UPIN
WI26462OtherLICENSE NUMBER