Provider Demographics
NPI:1124083969
Name:RENNIRT, DIANE A (MD)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:A
Last Name:RENNIRT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6420 DUTCHMANS PKWY, STE 195
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205
Mailing Address - Country:US
Mailing Address - Phone:502-928-0115
Mailing Address - Fax:502-928-0116
Practice Address - Street 1:3945 NANZ AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4937
Practice Address - Country:US
Practice Address - Phone:502-899-1100
Practice Address - Fax:502-614-6508
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY35001207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64034200Medicaid
KY64034200Medicaid
KYH11217Medicare UPIN
KY00546095Medicare Oscar/Certification