Healthcare Provider Details

I. General information

NPI: 1881651131
Provider Name (Legal Business Name): RUDOLPH S RUNNELS SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 SIMPSON HIGHWAY 149 STE 170
MAGEE MS
39111-3840
US

IV. Provider business mailing address

P.O. BOX 605
MAGEE MS
39111
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-9182
  • Fax: 601-849-5781
Mailing address:
  • Phone: 601-849-9182
  • Fax: 601-849-5781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number08417
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number08417
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: