Healthcare Provider Details

I. General information

NPI: 1932115938
Provider Name (Legal Business Name): RYAN T RUNYON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/28/2009
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:
Title or Position:
Credential:
Phone: