Provider Demographics
NPI:1689713638
Name:RENAISSANCE MEDICAL GROUP,INC
Entity Type:Organization
Organization Name:RENAISSANCE MEDICAL GROUP,INC
Other - Org Name:RENAISSANCETREATMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SYPHAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-925-2255
Mailing Address - Street 1:PO BOX 2966
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-0966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 EASTERN AVE STE B3
Practice Address - Street 2:
Practice Address - City:FAIRMOUNT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-1677
Practice Address - Country:US
Practice Address - Phone:301-925-2255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty