Basic Information
| Provider Information | |||||||||
| NPI: | 1487184800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FUNCDE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FUNCTIONAL ENDOCRINOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 969 READING RD STE N | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450402654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136041004 | ||||||||
| FaxNumber: | 5134370571 | ||||||||
| Practice Location | |||||||||
| Address1: | 969 READING RD STE N | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136041004 | ||||||||
| FaxNumber: | 5134370571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2017 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOLDENBERG | ||||||||
| AuthorizedOfficialFirstName: | NAILA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5136041004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 0079958 | 05 | OH | MEDICAID | 0233942 | 05 | OH | MEDICAID | 7100510650 | 05 | KY | MEDICAID |