Provider Demographics
NPI:1750441754
Name:CUNANAN MEDICAL CLINIC INC
Entity type:Organization
Organization Name:CUNANAN MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROMEO
Authorized Official - Middle Name:MIRANDA
Authorized Official - Last Name:CUNANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:770-251-4140
Mailing Address - Street 1:109 BULLSBORO DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263
Mailing Address - Country:US
Mailing Address - Phone:770-251-4140
Mailing Address - Fax:770-251-7275
Practice Address - Street 1:109 BULLSBORO DR
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263
Practice Address - Country:US
Practice Address - Phone:770-251-4140
Practice Address - Fax:770-251-7275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA442780335AMedicaid
GAGRP6582Medicare ID - Type Unspecified