Provider Demographics
NPI:1427061340
Name:RENAISSANCE PEDIATRICS PC
Entity type:Organization
Organization Name:RENAISSANCE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BAUCOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-488-2223
Mailing Address - Street 1:4012 RAINTREE RD
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3741
Mailing Address - Country:US
Mailing Address - Phone:757-488-2223
Mailing Address - Fax:757-488-8398
Practice Address - Street 1:4012 RAINTREE RD
Practice Address - Street 2:SUITE 200A
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3741
Practice Address - Country:US
Practice Address - Phone:757-488-2223
Practice Address - Fax:757-488-8398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty