Healthcare Provider Details

I. General information

NPI: 1023469590
Provider Name (Legal Business Name): SEAN M CUNNINGHAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 12/31/2021
Certification Date: 12/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15151 STANTON ST
WEST OLIVE MI
49460-8543
US

IV. Provider business mailing address

15151 STANTON ST
WEST OLIVE MI
49460-8543
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-1950
  • Fax: 231-727-5223
Mailing address:
  • Phone: 616-685-1950
  • Fax: 616-685-1980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101022669
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: