MEDICARE: DR. MARCIA WAYNE FUNDERBURK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME51523	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003875345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARCIA WAYNE FUNDERBURK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 44008
Second Line	:	UFJP PROVIDER ENROLLMENT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32231-4008
Country	:	US
Telephone Number	:	904-244-3660
Fax Number	:	904-244-3425

Provider Business Practice Location Address
First Line	:	1255 LILA ST
Second Line	:	UFJP LEM TURNER FAMILY PRACTICE CENTER
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-3550
Country	:	US
Telephone Number	:	904-244-5802
Fax Number	:	904-244-5791

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	12/02/2007

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