Provider Demographics
NPI:1619903317
Name:LASSILA, RENEE C (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:C
Last Name:LASSILA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:C
Other - Last Name:PALECEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5943 STADIUM DR
Mailing Address - Street 2:STE 3
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 EAST CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002
Practice Address - Country:US
Practice Address - Phone:269-286-7050
Practice Address - Fax:269-286-7051
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065740208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3214207Medicaid
G21569Medicare UPIN