Provider Demographics
NPI:1477979698
Name:RUNCIMAN, KENNETH ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ALLAN
Last Name:RUNCIMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3940 PHILLIPS AVE
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-4648
Mailing Address - Country:US
Mailing Address - Phone:270-564-8018
Mailing Address - Fax:270-534-5622
Practice Address - Street 1:3940 PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-4648
Practice Address - Country:US
Practice Address - Phone:270-564-8018
Practice Address - Fax:270-534-5622
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46739207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100358740Medicaid
KYK157510Medicare PIN