Provider Demographics
NPI:1962696112
Name:JAN H. CUNNINGHAM, MD, PLLC
Entity type:Organization
Organization Name:JAN H. CUNNINGHAM, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-345-4770
Mailing Address - Street 1:830 PENNSYLVANIA AVE
Mailing Address - Street 2:405
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-5302
Mailing Address - Country:US
Mailing Address - Phone:304-345-4770
Mailing Address - Fax:304-345-4774
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:405
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3302
Practice Address - Country:US
Practice Address - Phone:304-345-4770
Practice Address - Fax:304-345-4774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV09984261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0093478000Medicaid
WV0093478000Medicaid
WVJA9353301Medicare Oscar/Certification