Provider Demographics
NPI:1942594288
Name:MARIA C RENNA MD LLC
Entity Type:Organization
Organization Name:MARIA C RENNA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RENNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-634-3821
Mailing Address - Street 1:151 HAZARD AVE.
Mailing Address - Street 2:SUITE 9
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4588
Mailing Address - Country:US
Mailing Address - Phone:860-634-3821
Mailing Address - Fax:
Practice Address - Street 1:151 HAZARD AVE
Practice Address - Street 2:STE 9
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4584
Practice Address - Country:US
Practice Address - Phone:860-634-3821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-03
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044363207R00000X, 207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100049479Medicare PIN