Provider Demographics
NPI:1396726121
Name:FUNNEMAN, RICHARD DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DEAN
Last Name:FUNNEMAN
Suffix:
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 1:650 W TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-1227
Mailing Address - Country:US
Mailing Address - Phone:618-664-2531
Mailing Address - Fax:618-664-2553
Practice Address - Street 1:1442 N 8TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1031
Practice Address - Country:US
Practice Address - Phone:618-283-0266
Practice Address - Fax:618-283-0519
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36079619207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079619Medicaid
L10234OtherPIN
285910Medicare ID - Type Unspecified
IL036079619Medicaid