Healthcare Provider Details

I. General information

NPI: 1902049711
Provider Name (Legal Business Name): STEVEN JOHN RUNYAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FLYNN AVE
BURLINGTON VT
05401-5301
US

IV. Provider business mailing address

208 FLYNN AVE SUITE 3J
BURLINGTON VT
05401-5429
US

V. Phone/Fax

Practice location:
  • Phone: 802-488-6200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number032.0092778
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: