Provider Demographics
NPI:1508963711
Name:OLE W RENICK MD PC
Entity Type:Organization
Organization Name:OLE W RENICK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLE
Authorized Official - Middle Name:W
Authorized Official - Last Name:RENICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-772-3350
Mailing Address - Street 1:PO BOX 4127
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-0127
Mailing Address - Country:US
Mailing Address - Phone:540-344-9780
Mailing Address - Fax:540-344-7154
Practice Address - Street 1:3529 KEAGY RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7312
Practice Address - Country:US
Practice Address - Phone:540-772-3350
Practice Address - Fax:540-772-3393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C08964Medicare PIN