Healthcare Provider Details

I. General information

NPI: 1396726121
Provider Name (Legal Business Name): RICHARD DEAN FUNNEMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1442 N 8TH ST
VANDALIA IL
62471-1031
US

IV. Provider business mailing address

650 W TAYLOR ST
VANDALIA IL
62471-1227
US

V. Phone/Fax

Practice location:
  • Phone: 618-283-0266
  • Fax: 618-283-0519
Mailing address:
  • Phone: 618-664-2531
  • Fax: 618-664-2553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36079619
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: