Provider Demographics
NPI:1861466716
Name:RENNEBURG, JOHN N JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:N
Last Name:RENNEBURG
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LYONS ST
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-5599
Mailing Address - Country:US
Mailing Address - Phone:781-329-1400
Mailing Address - Fax:781-461-8691
Practice Address - Street 1:1 LYONS ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-5599
Practice Address - Country:US
Practice Address - Phone:781-329-1400
Practice Address - Fax:781-461-8691
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA70756207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
5930251OtherAETNA US HEALTHCARE
J13537OtherBLUE SHIELD HMO BLUE
3100588OtherMEDICAID WELFARE
784075OtherMVP HEALTH CARE
919279OtherFIRST HEALTH
AA2169OtherHARVARD PILGRIM HEALTHCAR
27197OtherHEALTHY START
J13537OtherBLUE CARE ELECT
J13537OtherMEDICARE B
MA3100588Medicaid
9900291OtherFALLON COMMUNITY HEALTH P
J13537OtherBLUE SHIELD INDEMNITY
0200021OtherEVERCARE
7107816OtherCIGNA HEALTH PLAN
27197OtherCHILDRENS MEDICAL SECURIT
MAJ13537Medicare ID - Type Unspecified
MA3100588Medicaid