Basic Information
| Provider Information | |||||||||
| NPI: | 1275512550 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RENZI | ||||||||
| FirstName: | RANDOLPH | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 CAMPUS BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226012896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406620306 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1880 AMHERST STREET | ||||||||
| Address2: | SUITE 100 AND SUITE 200 | ||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226012872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406620306 | ||||||||
| FaxNumber: | 8552642066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 18128 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RI0011X | 0101045302 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 502807 | 01 | VA | NCPPO | OTHER | C00075 | 01 | VA | MEDICARE GROUP | OTHER | 0085714000 | 05 | WV | MEDICAID | 000674642 | 01 | WV | MOUNTAIN STATE BCBS | OTHER | 006036155 | 05 | VA | MEDICAID | 068565 | 01 | VA | ANTHEM BCBS | OTHER | 16284 | 01 | VA | OPTIMA HEALTH SENTARA | OTHER | 9318661 | 01 | WV | MEDICARE GROUP | OTHER | 2119598 | 01 | VA | MAMSI | OTHER | 091241700 | 05 | MD | MEDICAID |