Healthcare Provider Details

I. General information

NPI: 1154435881
Provider Name (Legal Business Name): PRINCETON FAMILY MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 HARRISON ST
PRINCETON WV
24740-3011
US

IV. Provider business mailing address

PO BOX 1589
PRINCETON WV
24740-1589
US

V. Phone/Fax

Practice location:
  • Phone: 304-431-7100
  • Fax: 304-431-7112
Mailing address:
  • Phone: 304-431-7100
  • Fax: 304-431-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2005
License Number StateWV

VIII. Authorized Official

Name: DR. RYAN T. RUNYON
Title or Position: PHYSICIAN, OWNER
Credential: D.O.
Phone: 304-431-7100