Healthcare Provider Details

I. General information

NPI: 1275780660
Provider Name (Legal Business Name): RUNNELS PLASTIC SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 RIVER OAKS DRIVE
FLOWOOD MS
39232-9595
US

IV. Provider business mailing address

1057 RIVER OAKS DRIVE
FLOWOOD MS
39232-9595
US

V. Phone/Fax

Practice location:
  • Phone: 601-939-9778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number13960
License Number StateMS

VIII. Authorized Official

Name: RUDOLPH SCOTT RUNNELS JR.
Title or Position: OWNER
Credential: M,D.
Phone: 601-939-9778