Provider Demographics
NPI:1144532391
Name:RUNNELS, MARK
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:RUNNELS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MARSHALL ST
Mailing Address - Street 2:STE 301
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1687
Mailing Address - Country:US
Mailing Address - Phone:601-353-9900
Mailing Address - Fax:601-353-3654
Practice Address - Street 1:1421 N STATE ST
Practice Address - Street 2:STE 403
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1658
Practice Address - Country:US
Practice Address - Phone:601-353-9900
Practice Address - Fax:601-353-3654
Is Sole Proprietor?:No
Enumeration Date:2010-07-03
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-2356208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS23772OtherSTATE LICENSE