Provider Demographics
NPI:1841229127
Name:RENICH, MICHAELA E (MD)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:E
Last Name:RENICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 E STATESVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2590
Mailing Address - Country:US
Mailing Address - Phone:704-663-3063
Mailing Address - Fax:704-663-4873
Practice Address - Street 1:417 E STATESVILLE AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2590
Practice Address - Country:US
Practice Address - Phone:704-663-3063
Practice Address - Fax:704-663-4873
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98-01460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891187GMedicaid
NC891187GMedicaid
NC2263287BMedicare PIN