Provider Demographics
NPI:1710162003
Name:RENARD FOOT & ANKLE SPECIALIST LLC
Entity Type:Organization
Organization Name:RENARD FOOT & ANKLE SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RENARD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-882-9990
Mailing Address - Street 1:2005 S. LAKE PARK RD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915
Mailing Address - Country:US
Mailing Address - Phone:920-882-9990
Mailing Address - Fax:920-882-9544
Practice Address - Street 1:2005 S. LAKE PARK RD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915
Practice Address - Country:US
Practice Address - Phone:920-882-9990
Practice Address - Fax:920-882-9544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI847-025261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5535930001Medicare NSC
WI81094Medicare PIN