Basic Information
| Provider Information | |||||||||
| NPI: | 1972529014 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RENEKER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | STE 228 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
| FaxNumber: | 6166851850 | ||||||||
| Practice Location | |||||||||
| Address1: | 2373 64TH ST SW | ||||||||
| Address2: | STE 1200 | ||||||||
| City: | BYRON CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166853910 | ||||||||
| FaxNumber: | 6166853923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 02/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | RR063893 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301063893 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P61260 | 01 | MI | BCN | OTHER | 4445844 | 05 | MI | MEDICAID | 080D16151 | 01 | MI | BXBS | OTHER |