Healthcare Provider Details

I. General information

NPI: 1174595748
Provider Name (Legal Business Name): WILLIAM KENNARD RUNDELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 12/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 S. MAIN STREET SUITE 210
DAYTON OH
45409-2675
US

IV. Provider business mailing address

30 E. APPLE ST. STE 5253
DAYTON OH
45409
US

V. Phone/Fax

Practice location:
  • Phone: 937-228-4126
  • Fax: 937-228-0247
Mailing address:
  • Phone: 937-208-2552
  • Fax: 937-208-4286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number35043493R
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: