MEDICARE: MR. GREGORY S FUNK D.O.

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	D058	AL
2	208D00000X	General Practice Physician	DO58	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	511 22924	OTHER	AL	BCBS

General Provider Information

NPI Number	:	1881682284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY S FUNK D.O.

Provider Business Mailing Address
First Line	:	PO BOX 2029
Second Line	:
City	:	GULF SHORES
State	:	AL
Zip	:	36547
Country	:	US
Telephone Number	:	251-968-2441
Fax Number	:	251-968-5555

Provider Business Practice Location Address
First Line	:	3849 GULF SHORES PKWY
Second Line	:	SUITE 9
City	:	GULF SHORES
State	:	AL
Zip	:	36542
Country	:	US
Telephone Number	:	251-968-2441
Fax Number	:	251-968-5555

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

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	09/11/2012

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