Provider Demographics
NPI:1275780660
Name:RUNNELS PLASTIC SURGERY CENTER LLC
Entity Type:Organization
Organization Name:RUNNELS PLASTIC SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:RUNNELS
Authorized Official - Suffix:JR
Authorized Official - Credentials:M,D
Authorized Official - Phone:601-939-9778
Mailing Address - Street 1:1057 RIVER OAKS DRIVE
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1057 RIVER OAKS DRIVE
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9595
Practice Address - Country:US
Practice Address - Phone:601-939-9778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13960261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical