Provider Demographics
NPI:1811234032
Name:RENEW MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:RENEW MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-770-1006
Mailing Address - Street 1:2829 UNIVERSITY DR S STE 105
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6050
Mailing Address - Country:US
Mailing Address - Phone:701-404-9909
Mailing Address - Fax:877-813-3081
Practice Address - Street 1:2829 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6050
Practice Address - Country:US
Practice Address - Phone:701-404-9909
Practice Address - Fax:877-813-3081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44547207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty