Provider Demographics
NPI:1962510099
Name:ELLERBROEK, RENEE R (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:R
Last Name:ELLERBROEK
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 1:4637 121ST ST
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50323-2311
Mailing Address - Country:US
Mailing Address - Phone:515-655-7080
Mailing Address - Fax:515-655-7090
Practice Address - Street 1:4637 121ST ST
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50323-2311
Practice Address - Country:US
Practice Address - Phone:515-655-7080
Practice Address - Fax:515-655-7090
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24490207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1041525Medicaid
E47266Medicare UPIN
IA1041525Medicaid