Healthcare Provider Details

I. General information

NPI: 1619009537
Provider Name (Legal Business Name): BRIAN HAROLD CUNNINGHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 LOGAN AVE EMERGENCY DEPARTMENT
WATERLOO IA
50703-1916
US

IV. Provider business mailing address

1825 LOGAN AVE EMERGENCY DEPARTMENT
WATERLOO IA
50703-1916
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-3697
  • Fax: 319-235-3844
Mailing address:
  • Phone: 319-235-3697
  • Fax: 319-235-3844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberTEP 5009
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number37170
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: