Healthcare Provider Details

I. General information

NPI: 1285637090
Provider Name (Legal Business Name): CUNNINGHAM PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 SOUTHCREST PKWY
SOUTHAVEN MS
38671-4739
US

IV. Provider business mailing address

880 GREENLEAF RD
COLDWATER MS
38618-8133
US

V. Phone/Fax

Practice location:
  • Phone: 901-291-2400
  • Fax:
Mailing address:
  • Phone: 901-291-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD 16101
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD 11905
License Number StateMS

VIII. Authorized Official

Name: DR. MARK L CUNNINGHAM
Title or Position: OWNER
Credential: MD
Phone: 901-291-2400