Provider Demographics
NPI:1881979623
Name:CUNNINGHAM, MARIA LOUISE (LPT)
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:LOUISE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 TALON DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1848
Mailing Address - Country:US
Mailing Address - Phone:618-628-8211
Mailing Address - Fax:618-628-0883
Practice Address - Street 1:916 TALON DR
Practice Address - Street 2:SUITE 102
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1848
Practice Address - Country:US
Practice Address - Phone:618-628-8211
Practice Address - Fax:618-628-0883
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700187312081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL900068033OtherHNFS TRICARE NORTH REGION
IL900068033OtherBCBS OF IL
IL900068033OtherHEALTHLINK
IL900068033OtherUNITED HEALTHCARE
IL900068033OtherCIGNA
IL900068033OtherGHP
IL146703OtherMEDICARE PART A
IL900068033OtherAETNA
IL900068033OtherHNFS TRICARE NORTH REGION