Provider Demographics
NPI:1144201526
Name:CUNNINGHAM, JACK R (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9369
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36691-0369
Mailing Address - Country:US
Mailing Address - Phone:251-544-1926
Mailing Address - Fax:251-460-2846
Practice Address - Street 1:5 MOBILE INFIRMARY CIR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3513
Practice Address - Country:US
Practice Address - Phone:251-544-1926
Practice Address - Fax:251-460-2846
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL114952085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000017031Medicaid
AL104547Medicaid
AL009935328Medicaid
AL000017031Medicare PIN
AL009935328Medicaid