Provider Demographics
NPI:1659616852
Name:RENAISSANCE RECONSTRUCTIVE & AESTHETIC SURGERY INC
Entity Type:Organization
Organization Name:RENAISSANCE RECONSTRUCTIVE & AESTHETIC SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:AKERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-228-8500
Mailing Address - Street 1:2300 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 W ELM ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2541
Practice Address - Country:US
Practice Address - Phone:419-228-8500
Practice Address - Fax:419-228-8700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070442A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty