Provider Demographics
NPI:1558338764
Name:CUNNINGHAM, MARK ROY (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ROY
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 WEBSTER DR
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08343-9057
Mailing Address - Country:US
Mailing Address - Phone:856-881-7995
Mailing Address - Fax:
Practice Address - Street 1:542 BERLIN CROSS KEYS RD
Practice Address - Street 2:SUITE 1
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-4367
Practice Address - Country:US
Practice Address - Phone:856-740-0009
Practice Address - Fax:856-262-0469
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA0053400225100000X
PAPT-009193-E225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist