1053740399 NPI number — NIKI RUNGE MT-BC

Table of content: LAUREN MCNOBLE PA-C (NPI 1700395431)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053740399 NPI number — NIKI RUNGE MT-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUNGE
Provider First Name:
NIKI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MT-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053740399
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
212 E MAIN ST
Provider Second Line Business Mailing Address:
SUITE 211
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21801-5102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-523-4976
Provider Business Mailing Address Fax Number:
410-546-2376

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 211
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21801-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-523-4976
Provider Business Practice Location Address Fax Number:
410-546-2376
Provider Enumeration Date:
11/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5585503900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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