Healthcare Provider Details

I. General information

NPI: 1962696112
Provider Name (Legal Business Name): JAN H. CUNNINGHAM, MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 PENNSYLVANIA AVE 405
CHARLESTON WV
25302-3302
US

IV. Provider business mailing address

830 PENNSYLVANIA AVE 405
CHARLESTON WV
25302-5302
US

V. Phone/Fax

Practice location:
  • Phone: 304-345-4770
  • Fax: 304-345-4774
Mailing address:
  • Phone: 304-345-4770
  • Fax: 304-345-4774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number09984
License Number StateWV

VIII. Authorized Official

Name: DR. JAN HOWARD CUNNINGHAM
Title or Position: OWNER, MEMBER
Credential: MD
Phone: 304-345-4770