Provider Demographics
NPI:1568209872
Name:RENUVEN ACO PLLC
Entity type:Organization
Organization Name:RENUVEN ACO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-557-5706
Mailing Address - Street 1:2717 E OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1843
Mailing Address - Country:US
Mailing Address - Phone:423-926-2358
Mailing Address - Fax:
Practice Address - Street 1:3209 BRISTOL HWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1515
Practice Address - Country:US
Practice Address - Phone:423-926-2358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty