Basic Information
| Provider Information | |||||||||
| NPI: | 1790079564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUNCH | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 MERCY HEALTH BLVD | ||||||||
| Address2: | STE 2010 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452111103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139614335 | ||||||||
| FaxNumber: | 5139615769 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 MERCY HEALTH BLVD | ||||||||
| Address2: | STE 2010 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452111103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139614335 | ||||||||
| FaxNumber: | 5139615769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 09/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35.121147 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0086884 | 05 | OH | MEDICAID |