Provider Demographics
NPI:1336490739
Name:RUNEY, JUSTIN TYLER (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TYLER
Last Name:RUNEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9171
Mailing Address - Country:US
Mailing Address - Phone:843-797-5050
Mailing Address - Fax:843-797-3633
Practice Address - Street 1:2880 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9171
Practice Address - Country:US
Practice Address - Phone:843-797-5050
Practice Address - Fax:843-797-3633
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA 1842363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1874PAMedicaid
SCP01337423OtherRAILROAD MEDICARE PTAN
SCDU4331OtherARCIS HEALTHCARE GROUP RAILROAD MEDICARE PTAN
SCGP6337OtherARCIS HEALTHCARE GROUP MEDICAID NO.
SCD043OtherARCIS HEALTHCARE GROUP MEDICARE PTAN
SC1902246077OtherARCIS HEALTHCARE GROUP NPI
SCD043OtherARCIS HEALTHCARE GROUP MEDICARE PTAN
SCGP6337OtherARCIS HEALTHCARE GROUP MEDICAID NO.