Provider Demographics
NPI:1841460326
Name:FUNDERBURK MD
Entity type:Organization
Organization Name:FUNDERBURK MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMON
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNDERBURK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-659-9440
Mailing Address - Street 1:250 EXECUTIVE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1534
Mailing Address - Country:US
Mailing Address - Phone:336-659-9440
Mailing Address - Fax:336-659-9845
Practice Address - Street 1:250 EXECUTIVE PARK BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1534
Practice Address - Country:US
Practice Address - Phone:336-659-9440
Practice Address - Fax:336-659-9845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15068207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34172OtherBCBSNC
NC8934172Medicaid
NC34172OtherBCBSNC
NCC80603Medicare UPIN