Healthcare Provider Details

I. General information

NPI: 1720460363
Provider Name (Legal Business Name): RYAN TIMOTHY FUNK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 N KNOXVILLE AVE
PEORIA IL
61614-2017
US

IV. Provider business mailing address

7301 N KNOXVILLE AVE
PEORIA IL
61614-2017
US

V. Phone/Fax

Practice location:
  • Phone: 309-589-5900
  • Fax: 309-689-0312
Mailing address:
  • Phone: 309-589-5900
  • Fax: 309-689-0312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number125.066880
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: