Provider Demographics
NPI:1013162114
Name:PROFESSIONAL OB/GYN, INC.
Entity Type:Organization
Organization Name:PROFESSIONAL OB/GYN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-725-5282
Mailing Address - Street 1:970 E WASHINGTON ST STE 5F
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2181
Mailing Address - Country:US
Mailing Address - Phone:330-725-5282
Mailing Address - Fax:
Practice Address - Street 1:970 E WASHINGTON ST STE 5F
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2181
Practice Address - Country:US
Practice Address - Phone:330-725-5282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F89249Medicare UPIN
PR9270271Medicare PIN