Provider Demographics
NPI:1134166473
Name:RUNSCHKE, JURGEN GERNOT (MD)
Entity type:Individual
Prefix:DR
First Name:JURGEN
Middle Name:GERNOT
Last Name:RUNSCHKE
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 1:7091 E SHORE RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-1827
Mailing Address - Country:US
Mailing Address - Phone:616-204-5698
Mailing Address - Fax:
Practice Address - Street 1:630 KENMOOR AVE SE STE 105
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8626
Practice Address - Country:US
Practice Address - Phone:616-204-5698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321283207P00000X
IN01092546A207P00000X
MI4301080098208600000X, 2086S0129X, 207P00000X
MN65288207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJR080098OtherBCBS
MI104806285Medicaid
MI104951052Medicaid
MI104806285Medicaid
G06043026Medicare PIN
MI104951052Medicaid
P00261123Medicare PIN