Basic Information
Provider Information | |||||||||
NPI: | 1730293770 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FUNK | ||||||||
FirstName: | TINA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CONNOUR | ||||||||
OtherFirstName: | TINA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | O.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 773 | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | IL | ||||||||
PostalCode: | 619200773 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183955222 | ||||||||
FaxNumber: | 6183958552 | ||||||||
Practice Location | |||||||||
Address1: | 1200 N EAST ST | ||||||||
Address2: | STE. 2 | ||||||||
City: | OLNEY | ||||||||
State: | IL | ||||||||
PostalCode: | 624502499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6183955222 | ||||||||
FaxNumber: | 6183958552 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2006 | ||||||||
LastUpdateDate: | 06/26/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046009641 | IL | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 046009641 | 05 | IL |   | MEDICAID | P00174010 | 01 |   | RAILROAD MEDICARE | OTHER | 098727 | 01 | IL | HEALTH ALLIANCE | OTHER | 669964 | 01 | IL | HEALTHLINK | OTHER |