Provider Demographics
NPI:1285613091
Name:RUNCK, DENNIS W JR (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:W
Last Name:RUNCK
Suffix:JR
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:PO BOX 161715
Mailing Address - Street 2:
Mailing Address - City:BIG SKY
Mailing Address - State:MT
Mailing Address - Zip Code:59716-1715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:85 AMBER LILLY DRIVE
Practice Address - Street 2:
Practice Address - City:BIG SKY
Practice Address - State:MT
Practice Address - Zip Code:59716-1715
Practice Address - Country:US
Practice Address - Phone:651-292-2000
Practice Address - Fax:651-292-2178
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN310042085R0202X
MT108392085R0202X
ND100102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN259305000Medicaid
MN940000022Medicare ID - Type Unspecified
MNE51051Medicare UPIN