Provider Demographics
NPI:1407832041
Name:CUNNINGHAM JR, EDWIN J (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:J
Last Name:CUNNINGHAM JR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 PRIMACY PKWY
Mailing Address - Street 2:SUITE 241
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5745
Mailing Address - Country:US
Mailing Address - Phone:901-725-5846
Mailing Address - Fax:
Practice Address - Street 1:1265 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3415
Practice Address - Country:US
Practice Address - Phone:901-725-5846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14865207L00000X
MS22903207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3006016Medicaid
MS00012390Medicaid
MO201988706Medicaid
AR107439001Medicaid
050046696OtherMEDICARE RAILROAD
TN3075019OtherBLUECROSS BLUESHIELD
AR92419OtherBLUECROSS BLUESHIELD
AR107439001Medicaid