=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972794394
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMEKA STACEY-ANN FUNNY D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2007
-----------------------------------------------------
Last Update Date | 03/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1333 TAYLOR ST SUITE 6F
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29201-2923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-296-3273
-----------------------------------------------------
Fax | 803-296-7061
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 743904
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-3904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-296-7303
-----------------------------------------------------
Fax | 803-296-7330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | 39903
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | OS11222
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------