Provider Demographics
NPI:1780764639
Name:FUNK, ROBERT ANTHONY (PT, MSPT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ANTHONY
Last Name:FUNK
Suffix:
Gender:M
Credentials:PT, MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2846 MOODY PKWY STE 200
Practice Address - Street 2:
Practice Address - City:MOODY
Practice Address - State:AL
Practice Address - Zip Code:35004
Practice Address - Country:US
Practice Address - Phone:205-640-0257
Practice Address - Fax:205-640-0285
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3350225100000X
ALAL53150552251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051533197FUNMedicare PIN
AL51533197OtherBCBS PROVIDER ID
ALQ68289Medicare UPIN