| Entity Name: | DANIEL R. RENUART, M.D., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 06 Nov 2000 (24 years ago) |
| Document Number: | P00000104340 |
| FEI/EIN Number | 582583454 |
| Address: | 900 INGRAHAM AVE, HAINES CITY, FL, 33844, US |
| Mail Address: | 900 INGRAHAM AVE, HAINES CITY, FL, 33844, US |
| ZIP code: | 33844 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1346206935 | 2006-04-24 | 2011-10-19 | 900 INGRAHAM AVE, HAINES CITY, FL, 338444336, US | 900 INGRAHAM AVE, HAINES CITY, FL, 338444336, US | |||||||||||||||||||||||||||||||||||||
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| Phone | +1 863-421-6565 |
| Fax | 8634217474 |
Authorized person
| Name | DR. DANIEL ROBERT RENUART |
| Role | PRESIDENT |
| Phone | 8634216565 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | ME70353 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BLUE CROSS BLUE SHIELD # |
| Number | 74525 |
| State | FL |
| Issuer | MEDICAID |
| Number | 272383200 |
| State | FL |
| Issuer | MEDICAID |
| Number | 272383201 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MORRISON JOSEPH A | Agent | 4416 FLORIDA NATIONAL DRIVE, LAKELAND, FL, 33813 |
| Name | Role | Address |
|---|---|---|
| RENUART DANIEL R | Director | 901 POINTE EVA PLACE, HAINES CITY, FL, 33844 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G01304900013 | RAILROAD PARK PEDIATRICS | ACTIVE | 2001-10-31 | 2026-12-31 | No data | 900 INGRAHAM AVENUE, HAINES CITY, FL, 33844 |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
