Provider Demographics
NPI:1962491241
Name:RENZI, MICHAEL A (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:RENZI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:402 LIPPINCOTT DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4112
Mailing Address - Country:US
Mailing Address - Phone:856-782-3300
Mailing Address - Fax:856-504-8029
Practice Address - Street 1:318 WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:HADDON HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08035-1705
Practice Address - Country:US
Practice Address - Phone:856-547-6000
Practice Address - Fax:856-546-3189
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MB05949300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6852505Medicaid
NJ576295Medicare PIN
077356 SK3Medicare PIN
NJ6852505Medicaid