Healthcare Provider Details

I. General information

NPI: 1568698066
Provider Name (Legal Business Name): SCOTT ELLIS CUNNINGHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 05/27/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LEBAUER GASTROENTEROLOGY 520 N ELAM AVE
GREENSBORO NC
27403-1127
US

IV. Provider business mailing address

1 JARRETT WHITE RD TRIPLER ARMY MEDICAL CENTER
TRIPLER ARMY MEDICAL CENTER HI
96859-5001
US

V. Phone/Fax

Practice location:
  • Phone: 336-547-1745
  • Fax: 336-547-1824
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2019-02937
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: