Provider Demographics
NPI:1386602662
Name:RENNER, MICHAEL J (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:RENNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:140 OSIGIAN BLVD
Mailing Address - Street 2:BLDG 300
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-7879
Mailing Address - Country:US
Mailing Address - Phone:478-329-0291
Mailing Address - Fax:478-333-3609
Practice Address - Street 1:140 OSIGIAN BLVD
Practice Address - Street 2:BLDG 300
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7879
Practice Address - Country:US
Practice Address - Phone:478-329-0291
Practice Address - Fax:478-333-3609
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2013-02-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA038594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA080178726Medicaid
GAGRP4178OtherMEDICARE GROUP NUMBER
GA080178726OtherRAIL ROAD MEDICARE NUMBER
GA08BDVTX GRP4178Medicare PIN
GA08BDVTXMedicare ID - Type Unspecified
GA080178726OtherRAIL ROAD MEDICARE NUMBER