Provider Demographics
NPI:1568977940
Name:RENAISSANCE MEDICAL CARE
Entity Type:Organization
Organization Name:RENAISSANCE MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:OLIVER
Authorized Official - Last Name:HALSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-285-3911
Mailing Address - Street 1:284 BLEVINS BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VT
Mailing Address - Zip Code:24202
Mailing Address - Country:US
Mailing Address - Phone:276-285-3911
Mailing Address - Fax:276-285-3920
Practice Address - Street 1:284 BLEVINS BOULEVARD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202
Practice Address - Country:US
Practice Address - Phone:276-285-3911
Practice Address - Fax:276-285-3920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-07
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty