Provider Demographics
NPI:1326041146
Name:CUNNINGHAM, MARK L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
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 1:880 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:901-291-2427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16101208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3020096Medicaid
MS00112219Medicaid
250006423Medicare PIN
TNA98378Medicare UPIN
TN3020096Medicaid
MS00112219Medicaid