=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801241658
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERIC RUNYON, D.O., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2016
-----------------------------------------------------
Last Update Date | 04/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11760 SW 40TH ST SUITE 654
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-3582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-615-6123
-----------------------------------------------------
Fax | 786-615-6103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11760 SW 40TH ST SUITE 654
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33175-3582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-615-6123
-----------------------------------------------------
Fax | 786-615-6103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. CLAUDIA KNICKERBOKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-615-6123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | OS8317
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | OS4300
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------