Healthcare Provider Details

I. General information

NPI: 1841678083
Provider Name (Legal Business Name): CHASTITY RUNGE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W GRAND AVE MEDICAL EDUCATION DEPARTMENT
DAYTON OH
45405-4720
US

IV. Provider business mailing address

107 BURDSALL AVE
FORT MITCHELL KY
41017-2823
US

V. Phone/Fax

Practice location:
  • Phone: 937-723-3245
  • Fax: 937-723-5016
Mailing address:
  • Phone: 859-916-1736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number390200000
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number34.013166
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: