Provider Demographics
NPI:1831324144
Name:RENEWAL DERMATOLOGY PLLC
Entity Type:Organization
Organization Name:RENEWAL DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTLIPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-753-9860
Mailing Address - Street 1:7512 GARDNER PARK DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3414
Mailing Address - Country:US
Mailing Address - Phone:703-753-9860
Mailing Address - Fax:703-753-9863
Practice Address - Street 1:7512 GARDNER PARK DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3414
Practice Address - Country:US
Practice Address - Phone:703-753-9860
Practice Address - Fax:703-753-9863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-17
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10787Medicare PIN