=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447449103
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENJAMIN J. CUNNINGHAM, M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2007
-----------------------------------------------------
Last Update Date | 05/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 N GRANT AVE SUITE 200
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79761-4503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-331-1234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1808
-----------------------------------------------------
City | ODESSA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79760-1808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BENJAMIN CUNNINGHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 432-331-1234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | L3618
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------