Provider Demographics
NPI:1982606851
Name:RENAISSANCE MEDICAL LLC
Entity Type:Organization
Organization Name:RENAISSANCE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:606-878-0453
Mailing Address - Street 1:1380 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-1615
Mailing Address - Country:US
Mailing Address - Phone:606-878-0453
Mailing Address - Fax:606-878-1862
Practice Address - Street 1:4530 BISHOP LN
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4561
Practice Address - Country:US
Practice Address - Phone:502-961-8560
Practice Address - Fax:606-878-1862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYHME00021332B00000X
KYMG0190332B00000X
332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
164438OtherIN STATE DEPT HLTH CSH
S864OtherANTHEM
2196098OtherAETNA
040021100OtherFEDERAL BLACK LUNG PROGRA
119010OtherBCBS MI ABP PLAN
C82008OtherCHI
110110OtherAMERICAN BENEFIT PLAN
228579OtherGHP
006895400OtherUS DEPT OF LABOR
26404V2111OtherAHDS
KY7100165610Medicaid
C82003OtherCHI
000000070422OtherANTHEM
KY7100166520Medicaid
822271OtherBCBS PENN
KY1079739OtherPASSPORT
1171574OtherCUMBERLAND HEALTHCARE
KY7100165610Medicaid