Provider Demographics
NPI:1285637090
Name:CUNNINGHAM PHYSICAL MEDICINE
Entity Type:Organization
Organization Name:CUNNINGHAM PHYSICAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-291-2400
Mailing Address - Street 1:880 GREENLEAF RD
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MS
Mailing Address - Zip Code:38618-8133
Mailing Address - Country:US
Mailing Address - Phone:901-291-2400
Mailing Address - Fax:
Practice Address - Street 1:7601 SOUTHCREST PKWY
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4739
Practice Address - Country:US
Practice Address - Phone:901-291-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 16101208100000X
MSMD 11905208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302G702808Medicare PIN
TN103G705178Medicare PIN