Provider Demographics
NPI:1639221179
Name:RUNNELS, RUDOLPH SCOTT JR (MD)
Entity Type:Individual
Prefix:MR
First Name:RUDOLPH
Middle Name:SCOTT
Last Name:RUNNELS
Suffix:JR
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 1:1055 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:601-939-9778
Mailing Address - Fax:601-939-9416
Practice Address - Street 1:1055 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:601-939-9416
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13960208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115139Medicaid
MS00115139Medicaid