Provider Demographics
NPI: | 1437357274 |
---|---|
Name: | FUNKE, FREDERICK W JR (MD) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | FREDERICK |
Middle Name: | W |
Last Name: | FUNKE |
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: | 3601 LADSON RD |
Mailing Address - Street 2: | STE 100 |
Mailing Address - City: | LADSON |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29456-4304 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-285-2500 |
Mailing Address - Fax: | 843-285-2505 |
Practice Address - Street 1: | 3601 LADSON RD |
Practice Address - Street 2: | STE 100 |
Practice Address - City: | LADSON |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29456-4304 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-285-2500 |
Practice Address - Fax: | 843-285-2505 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-07-03 |
Last Update Date: | 2017-04-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | 29994 | 207RC0000X, 207RI0011X, 207UN0902X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No | 207RI0011X | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No | 207UN0902X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy |