Provider Demographics
NPI:1619232469
Name:RENEWAL DERMATOLOGY & MEDSPA, P.C.
Entity Type:Organization
Organization Name:RENEWAL DERMATOLOGY & MEDSPA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAGGIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-753-9860
Mailing Address - Street 1:7512 GARDNER PARK DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3414
Mailing Address - Country:US
Mailing Address - Phone:703-753-9860
Mailing Address - Fax:703-753-9863
Practice Address - Street 1:7512 GARDNER PARK DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3414
Practice Address - Country:US
Practice Address - Phone:703-753-9860
Practice Address - Fax:703-753-9863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty