Provider Demographics
NPI:1023096781
Name:DEWEESE, RENEE RAIMONDI (MD)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:RAIMONDI
Last Name:DEWEESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:MICHELLE
Other - Last Name:RAIMONDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:620 SUMMIT CROSSING PL
Mailing Address - Street 2:STE 106
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2176
Mailing Address - Country:US
Mailing Address - Phone:704-867-8021
Mailing Address - Fax:704-864-4606
Practice Address - Street 1:SUMMIT CROSSING PLACE
Practice Address - Street 2:STE 106
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-867-8021
Practice Address - Fax:704-864-4606
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000003942085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
7543124OtherAETNA PPO
NC89126JUMedicaid
1643188OtherUNITED HEALTHCARE
2353072OtherAETNA HMO
300110411OtherRAILROAD MEDICARE
126JUOtherBLUE CROSS BLUE SHIELD
37295OtherPARTNERS
97384OtherMEDCOST
SCN00394Medicare ID - Type Unspecified
126JUOtherBLUE CROSS BLUE SHIELD
37295OtherPARTNERS