Provider Demographics
NPI:1124091087
Name:RENUCCI, ANN M (MD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:RENUCCI
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:1000 E PARIS AVE SE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3680
Mailing Address - Country:US
Mailing Address - Phone:616-949-2001
Mailing Address - Fax:616-949-8620
Practice Address - Street 1:1000 E PARIS AVE SE
Practice Address - Street 2:SUITE 130
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3680
Practice Address - Country:US
Practice Address - Phone:616-949-2001
Practice Address - Fax:616-949-8620
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2017-04-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301079485174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104457907Medicaid
MI104457907Medicaid
MIN85130003Medicare PIN