Healthcare Provider Details

I. General information

NPI: 1548222334
Provider Name (Legal Business Name): MICHAEL COLIN FUNK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 N MAPLE ST
EFFINGHAM IL
62401-2006
US

IV. Provider business mailing address

PO BOX 740209 DEPT 1073
ATLANTA GA
30374-0209
US

V. Phone/Fax

Practice location:
  • Phone: 217-342-2121
  • Fax:
Mailing address:
  • Phone: 941-360-1566
  • Fax: 941-358-9818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: