Provider Demographics
NPI:1104801018
Name:RUNYAN, KEITH ROBERTS (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ROBERTS
Last Name:RUNYAN
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 1:3305 W MARITANA DR
Mailing Address - Street 2:
Mailing Address - City:ST PETE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33706
Mailing Address - Country:US
Mailing Address - Phone:813-502-0529
Mailing Address - Fax:
Practice Address - Street 1:3305 W MARITANA DR
Practice Address - Street 2:
Practice Address - City:ST PETE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33706
Practice Address - Country:US
Practice Address - Phone:813-502-0529
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62416207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME62416OtherSTATE LICENSE NUMBER
FL262962300Medicaid
FLE82527Medicare UPIN