Healthcare Provider Details

I. General information

NPI: 1578112983
Provider Name (Legal Business Name): PETER CUNNINGHAM D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AUDUBON PLAZA DR OFC L2
LOUISVILLE KY
40217-1318
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE STE 308
PEORIA IL
61614-5099
US

V. Phone/Fax

Practice location:
  • Phone: 502-636-7111
  • Fax:
Mailing address:
  • Phone: 309-691-6610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005968
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005968
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number246958
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: