Provider Demographics
NPI:1093869851
Name:TIMOTHY C. RUNYON, D.P.M. P.A.
Entity Type:Organization
Organization Name:TIMOTHY C. RUNYON, D.P.M. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:KINMON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:561-995-0229
Mailing Address - Street 1:1401 16TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-4123
Mailing Address - Country:US
Mailing Address - Phone:727-894-0794
Mailing Address - Fax:727-895-1215
Practice Address - Street 1:1401 16TH ST N
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-4123
Practice Address - Country:US
Practice Address - Phone:727-894-0794
Practice Address - Fax:727-895-1215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1101213ER0200X, 213ES0000X, 213ES0103X, 332B00000X, 332BC3200X
332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Single Specialty
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing Site
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340415300Medicaid
FL340415300Medicaid