Provider Demographics
NPI:1902846017
Name:CUNNINGHAM, BRYAN G (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:G
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 1:1007 LINCOLNWAY
Mailing Address - Street 2:POST OFFICE BOX 1539
Mailing Address - City:LAPORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3201
Mailing Address - Country:US
Mailing Address - Phone:219-326-2403
Mailing Address - Fax:219-326-2385
Practice Address - Street 1:1007 LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:LAPORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3201
Practice Address - Country:US
Practice Address - Phone:219-326-2403
Practice Address - Fax:219-326-2385
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036025A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ING49333Medicare UPIN