Provider Demographics
NPI:1205148616
Name:RENAISSANCE MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:RENAISSANCE MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DIMPLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIPATHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-831-5913
Mailing Address - Street 1:430 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2136
Mailing Address - Country:US
Mailing Address - Phone:313-831-5913
Mailing Address - Fax:313-831-5991
Practice Address - Street 1:430 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2136
Practice Address - Country:US
Practice Address - Phone:313-831-5913
Practice Address - Fax:313-831-5991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty