Healthcare Provider Details

I. General information

NPI: 1023293701
Provider Name (Legal Business Name): RENEE ELIZABETH FUNCHES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 FAIR LAKES PKWY KAISER PERMANENTE FAIR OAKS MEDICAL CENTER
FAIRFAX VA
22033-3952
US

IV. Provider business mailing address

2101 E JEFFERSON ST KAISER PERMANENTE MEDICARE ENROLLMENT
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 703-934-5700
  • Fax:
Mailing address:
  • Phone: 301-816-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2061
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number0101251300
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: