Provider Demographics
NPI:1487608931
Name:RENAISSANCE IMAGING MEDICAL ASSOCIATES, INC.
Entity type:Organization
Organization Name:RENAISSANCE IMAGING MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-309-6984
Mailing Address - Street 1:PO BOX 85491
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5491
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12554 RIATA VISTA CIR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6431
Practice Address - Country:US
Practice Address - Phone:888-965-0083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ67806ZOtherBLUE SHIELD
CG2517OtherRAILROAD MEDICARE
ZZZ33823ZOtherBLUE SHIELD
ZZZ65816ZOtherBLUE SHIELD
CAGR0086071Medicaid
ZZZ65767ZOtherBLUE SHIELD
ZZZ59788ZOtherBLUE SHIELD
CAGR0086070Medicaid
ZZZ69508ZOtherBLUE SHIELD
CAGR0086070Medicaid
CG2517OtherRAILROAD MEDICARE