Provider Demographics
NPI:1568403624
Name:CUNNINGHAM, SCOTT MARK (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MARK
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 N ERIE ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-1095
Mailing Address - Country:US
Mailing Address - Phone:716-753-4104
Mailing Address - Fax:716-753-4230
Practice Address - Street 1:200 E 3RD ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-5433
Practice Address - Country:US
Practice Address - Phone:716-661-8330
Practice Address - Fax:716-661-8364
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006556207P00000X
PAOS010138L207P00000X
NY288392-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2250835Medicaid
OH942460636226OtherCARESOURCE
PA0017158750008Medicaid
PA0017158750009Medicaid
OHP00220889OtherMEDICARE RR-GA
PA0017158750008Medicaid
OHCU0829515Medicare ID - Type Unspecified
PA0017158750009Medicaid