Healthcare Provider Details

I. General information

NPI: 1609067941
Provider Name (Legal Business Name): BRAD C RUNYAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 E HARMONY RD UNIT 350
FORT COLLINS CO
80528-3404
US

IV. Provider business mailing address

2121 E HARMONY RD UNIT 350
FORT COLLINS CO
80528-3404
US

V. Phone/Fax

Practice location:
  • Phone: 970-212-0169
  • Fax:
Mailing address:
  • Phone: 970-212-0169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number35264
License Number StateCO

VIII. Authorized Official

Name: MRS. BRENDA DREW
Title or Position: OFFICE MANAGER
Credential:
Phone: 970-212-0169