Provider Demographics
NPI:1548429020
Name:RENEE WESLOW MD PA
Entity Type:Organization
Organization Name:RENEE WESLOW MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:G
Authorized Official - Last Name:WESLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-784-0071
Mailing Address - Street 1:425 LIVINGSTON ST
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:NORWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07648-1821
Mailing Address - Country:US
Mailing Address - Phone:201-784-0071
Mailing Address - Fax:201-784-2662
Practice Address - Street 1:425 LIVINGSTON ST
Practice Address - Street 2:SUITE # 1
Practice Address - City:NORWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07648-1821
Practice Address - Country:US
Practice Address - Phone:201-784-0071
Practice Address - Fax:201-784-2662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA64674261Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG22713Medicare UPIN