Provider Demographics
NPI:1972517837
Name:RUNKEL, GREGORY W (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
Last Name:RUNKEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:102 RACE TRACK RD
Practice Address - Street 2:SUITE 1
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-4004
Practice Address - Country:US
Practice Address - Phone:518-585-6708
Practice Address - Fax:518-585-3260
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY192862208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01700283Medicaid
NY01700283Medicaid
NYJ400025927Medicare PIN