Provider Demographics
NPI:1811995673
Name:ABRAHAM, RENNY (MD)
Entity type:Individual
Prefix:
First Name:RENNY
Middle Name:
Last Name:ABRAHAM
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 1:5701 BOW POINTE DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3199
Mailing Address - Country:US
Mailing Address - Phone:248-625-2621
Mailing Address - Fax:248-625-2622
Practice Address - Street 1:834 S LAPEER RD STE 100
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-5039
Practice Address - Country:US
Practice Address - Phone:248-384-8320
Practice Address - Fax:248-384-8321
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074879208000000X
MIRA074879207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP01235908OtherRAILROAD MEDICARE IND PIN
MI1811995673Medicaid
MI1106312642OtherBCBS IND
MIP01235908OtherRAILROAD MEDICARE IND PIN
MIP01235908OtherRAILROAD MEDICARE IND PIN
MIH91041Medicare UPIN
MIP01235908OtherRAILROAD MEDICARE IND PIN
MIH91041Medicare UPIN