Provider Demographics
NPI:1659681880
Name:MARK R. FUNK, M.D., L.L.C.
Entity Type:Organization
Organization Name:MARK R. FUNK, M.D., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-322-0667
Mailing Address - Street 1:700 CENTER ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-1546
Mailing Address - Country:US
Mailing Address - Phone:706-322-0667
Mailing Address - Fax:706-322-0873
Practice Address - Street 1:700 CENTER ST
Practice Address - Street 2:SUITE 503
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1546
Practice Address - Country:US
Practice Address - Phone:706-322-0667
Practice Address - Fax:706-322-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0066701HMedicaid
GAD29514Medicare UPIN
GA0066701HMedicaid