Healthcare Provider Details

I. General information

NPI: 1841217585
Provider Name (Legal Business Name): BRIAN KEITH RUNDALL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 W FARIS RD STE 320
GREENVILLE SC
29605-4281
US

IV. Provider business mailing address

300 E MCBEE AVE STE 401
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-1200
  • Fax: 864-455-1209
Mailing address:
  • Phone: 864-522-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberDO-04423
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number307379
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number83753
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: