Provider Demographics
NPI:1871504720
Name:RUNGE, ROBERT CHARLES JR (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:CHARLES
Last Name:RUNGE
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N KOELLER ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-4111
Mailing Address - Country:US
Mailing Address - Phone:920-233-8739
Mailing Address - Fax:920-233-8732
Practice Address - Street 1:420 N KOELLER ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-4111
Practice Address - Country:US
Practice Address - Phone:920-233-8739
Practice Address - Fax:920-233-8732
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4415-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40314500Medicaid
WI40314500Medicaid