Provider Demographics
NPI:1174595748
Name:RUNDELL, WILLIAM KENNARD (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KENNARD
Last Name:RUNDELL
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 1:30 E. APPLE ST.
Mailing Address - Street 2:STE 5253
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409
Mailing Address - Country:US
Mailing Address - Phone:937-208-2552
Mailing Address - Fax:937-208-4286
Practice Address - Street 1:1520 S. MAIN STREET
Practice Address - Street 2:SUITE 210
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2675
Practice Address - Country:US
Practice Address - Phone:937-228-4126
Practice Address - Fax:937-228-0247
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043493R2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0413065Medicaid
OHB96450Medicare UPIN
OHRU0465212Medicare ID - Type Unspecified