1467568519 NPI number — SAM R. FUNK, O.D., P.A.

Table of content: (NPI 1467568519)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467568519 NPI number — SAM R. FUNK, O.D., P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAM R. FUNK, O.D., P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467568519
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 N FRANKLIN AVE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLBY
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67701-2342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-462-3348
Provider Business Mailing Address Fax Number:
785-462-3599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 N FRANKLIN AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLBY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67701-2342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-462-3348
Provider Business Practice Location Address Fax Number:
785-462-3599
Provider Enumeration Date:
08/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FUNK
Authorized Official First Name:
SAM
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
785-462-3348

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  11113 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12589230 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 201083380A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100090170A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 656990 . This is a "FIRST GUARD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 005149 . This is a "BC/BS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 001269 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".