MEDICARE: DR. MARK DOUGLAS CUNNINGHAM D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	42179	MN

General Provider Information

NPI Number	:	1548290950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK DOUGLAS CUNNINGHAM D.O.

Provider Business Mailing Address
First Line	:	HWY 1
Second Line	:	24760 HOSPITAL DRIVE
City	:	RED LAKE
State	:	MN
Zip	:	56671-0249
Country	:	US
Telephone Number	:	218-679-3912
Fax Number	:	218-679-0135

Provider Business Practice Location Address
First Line	:	HIGHWAY 1
Second Line	:
City	:	RED LAKE
State	:	MN
Zip	:	56671-0249
Country	:	US
Telephone Number	:	218-679-3912
Fax Number	:	218-679-0135

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	07/08/2007

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