Provider Demographics
NPI:1750310900
Name:SMITH, RENEE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:MARIE
Other - Last Name:BLAVAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:333 PINE RIDGE BLVD
Mailing Address - Street 2:SUITE 1-905
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4120
Mailing Address - Country:US
Mailing Address - Phone:715-847-2000
Mailing Address - Fax:
Practice Address - Street 1:110 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2710
Practice Address - Country:US
Practice Address - Phone:715-623-2351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIBB8982591OtherDEA
WIBB8982591OtherDEA
WI004559065Medicare PIN