Provider Demographics
NPI:1982682597
Name:CHARLES W CUNNINGHAM DO LLC
Entity Type:Organization
Organization Name:CHARLES W CUNNINGHAM DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-729-5533
Mailing Address - Street 1:1010 W HIGHWAY 32
Mailing Address - Street 2:P.O. BOX 399
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-2356
Mailing Address - Country:US
Mailing Address - Phone:572-729-5533
Mailing Address - Fax:573-729-7754
Practice Address - Street 1:1010 W HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-2356
Practice Address - Country:US
Practice Address - Phone:572-729-5533
Practice Address - Fax:573-729-7754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33540207Q00000X
261QR1300X
MO121934363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO263824Medicare ID - Type UnspecifiedMEDICARE RHC