Healthcare Provider Details

I. General information

NPI: 1326041146
Provider Name (Legal Business Name): MARK L CUNNINGHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 01/14/2015
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: 901-291-2427
  • Fax:
Mailing address:
  • Phone: 901-291-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number16101
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: