Provider Demographics
NPI:1720287071
Name:RENAISSANCE FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:RENAISSANCE FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-948-9500
Mailing Address - Street 1:2580 CHARLESTOWN RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150
Mailing Address - Country:US
Mailing Address - Phone:812-948-9500
Mailing Address - Fax:812-948-9600
Practice Address - Street 1:2580 CHARLESTOWN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150
Practice Address - Country:US
Practice Address - Phone:812-948-9500
Practice Address - Fax:812-948-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036882A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100116610AMedicaid
INE11196Medicare UPIN