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General NPI Number Information
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NPI Number | 1104883966
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Entity Type | Individual
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Provider Name | JASON GLEN FUNDERBURK MD
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Gender | Male
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Dates
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Enumeration Date | 04/27/2006
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Last Update Date | 04/09/2014
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Provider Practice Location Address
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Address Line | 116 CONCORD RD SUITE 500
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City | KNOXVILLE
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State | TN
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Zip | 37934-2940
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Country | US
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Telephone | 865-777-6880
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Fax |
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Provider Business Mailing Address
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Address Line | 116 CONCORD RD SUITE 500
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City | KNOXVILLE
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State | TN
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Zip | 37934-2940
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Country | US
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Telephone | 865-777-6880
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | ME 93065
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | 47153
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | 4301102162
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License Number State | MI
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