Provider Demographics
NPI:1609097112
Name:RENAISSANCE PRIMARY CARE AND WELLNESS GROUP LLC
Entity Type:Organization
Organization Name:RENAISSANCE PRIMARY CARE AND WELLNESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LINDIWE
Authorized Official - Middle Name:F
Authorized Official - Last Name:GREENWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-772-8001
Mailing Address - Street 1:5500 KNOLL NORTH DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2209
Mailing Address - Country:US
Mailing Address - Phone:410-772-8001
Mailing Address - Fax:410-772-8004
Practice Address - Street 1:5500 KNOLL NORTH DR
Practice Address - Street 2:SUITE 250
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2209
Practice Address - Country:US
Practice Address - Phone:410-772-8001
Practice Address - Fax:410-772-8004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405788100Medicaid
MD75XBLFOtherMD BLUE SHIELD
MD33760001OtherBLUE CHOICE
MD405788100Medicaid