Provider Demographics
NPI:1770536195
Name:RENNER, GREGORY (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:RENNER
Suffix:
Gender:M
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:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:525 N KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8367
Practice Address - Country:US
Practice Address - Phone:573-882-7903
Practice Address - Fax:573-884-4607
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO362502082S0099X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO850000049OtherRR MEDICARE
MO201550605Medicaid
MOP00419171OtherRAILROAD MEDICARE
MO019011109Medicare PIN
A13059Medicare UPIN
MOP00419171OtherRAILROAD MEDICARE