Provider Demographics
NPI:1992867311
Name:RENAISSANCE MEDICAL GROUP
Entity Type:Organization
Organization Name:RENAISSANCE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-684-5722
Mailing Address - Street 1:4440 W. 95TH STREET
Mailing Address - Street 2:ROOM 250 NORTH
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453
Mailing Address - Country:US
Mailing Address - Phone:708-684-5722
Mailing Address - Fax:708-684-1405
Practice Address - Street 1:4440 W 95TH ST
Practice Address - Street 2:ROOM 250 NORTH
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2600
Practice Address - Country:US
Practice Address - Phone:708-684-5722
Practice Address - Fax:708-684-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty