Healthcare Provider Details

I. General information

NPI: 1346402740
Provider Name (Legal Business Name): MATTHEW DAVID RUNNEBOHM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 2ND ST
BLOOMINGTON IN
47403-2317
US

IV. Provider business mailing address

2165 HARRODSBURG RD
SPRINGVILLE IN
47462-5123
US

V. Phone/Fax

Practice location:
  • Phone: 317-604-0059
  • Fax:
Mailing address:
  • Phone: 317-604-0059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01069053A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: