Healthcare Provider Details

I. General information

NPI: 1912135096
Provider Name (Legal Business Name): KRISTOPHER TODD CUNNINGHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-0182
  • Fax: 217-545-4735
Mailing address:
  • Phone: 217-588-2624
  • Fax: 217-757-7550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036132674
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125-056927
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: