Healthcare Provider Details

I. General information

NPI: 1447249750
Provider Name (Legal Business Name): CHARLES KEITH FUNDERBURK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 MEDICAL CENTER DR
CLANTON AL
35045-2332
US

IV. Provider business mailing address

PO BOX 1850
CLANTON AL
35046-1850
US

V. Phone/Fax

Practice location:
  • Phone: 205-755-5700
  • Fax: 205-755-4966
Mailing address:
  • Phone: 205-755-5700
  • Fax: 205-755-4966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number8358
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: