Basic Information
| Provider Information | |||||||||
| NPI: | 1336490739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUNEY | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | TYLER | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2880 TRICOM ST | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437975050 | ||||||||
| FaxNumber: | 8437973633 | ||||||||
| Practice Location | |||||||||
| Address1: | 2880 TRICOM ST | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437975050 | ||||||||
| FaxNumber: | 8437973633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2012 | ||||||||
| LastUpdateDate: | 03/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA 1842 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA 1842 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1874PA | 05 | SC | MEDICAID | P01337423 | 01 | SC | RAILROAD MEDICARE PTAN | OTHER | DU4331 | 01 | SC | ARCIS HEALTHCARE GROUP RAILROAD MEDICARE PTAN | OTHER | GP6337 | 01 | SC | ARCIS HEALTHCARE GROUP MEDICAID NO. | OTHER | D043 | 01 | SC | ARCIS HEALTHCARE GROUP MEDICARE PTAN | OTHER | 1902246077 | 01 | SC | ARCIS HEALTHCARE GROUP NPI | OTHER |