Healthcare Provider Details

I. General information

NPI: 1588677710
Provider Name (Legal Business Name): ABILENE SPORTS MEDICINE & ORTHOPEDICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2074 ANTILLEY RD
ABILENE TX
79606-5209
US

IV. Provider business mailing address

2074 ANTILLEY RD
ABILENE TX
79606-5209
US

V. Phone/Fax

Practice location:
  • Phone: 325-698-3865
  • Fax: 325-793-1295
Mailing address:
  • Phone: 325-698-3865
  • Fax: 325-793-1295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberJ4131
License Number StateTX

VIII. Authorized Official

Name: DALE A. FUNK
Title or Position: OWNER
Credential: M.D.
Phone: 325-698-3865