1730293770 NPI number — DR. TINA M FUNK OD

Table of content: DR. TINA M FUNK OD (NPI 1730293770)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730293770 NPI number — DR. TINA M FUNK OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUNK
Provider First Name:
TINA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONNOUR
Provider Other First Name:
TINA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730293770
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 773
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61920-0773
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-395-5222
Provider Business Mailing Address Fax Number:
618-395-8552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 N EAST ST
Provider Second Line Business Practice Location Address:
STE. 2
Provider Business Practice Location Address City Name:
OLNEY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62450-2499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-395-5222
Provider Business Practice Location Address Fax Number:
618-395-8552
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046009641 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 046009641 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00174010 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 098727 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 669964 . This is a "HEALTHLINK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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