Basic Information
Provider Information | |||||||||
NPI: | 1619085925 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CUNNINGHAM | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | RUSSELL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1080 | ||||||||
Address2: |   | ||||||||
City: | BURKESVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 427171080 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6066768186 | ||||||||
FaxNumber: | 2708586655 | ||||||||
Practice Location | |||||||||
Address1: | 333 BOGLE ST | ||||||||
Address2: |   | ||||||||
City: | SOMERSET | ||||||||
State: | KY | ||||||||
PostalCode: | 425032873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6066780705 | ||||||||
FaxNumber: | 6066762807 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/27/2006 | ||||||||
LastUpdateDate: | 06/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 32435 | KY | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 000000108398 | 01 | KY | BLUE CROSS BLUE SHIELD | OTHER | 611371633 | 01 | KY | IRS TAXPAYER ID NUMBER | OTHER | 64324353 | 05 | KY |   | MEDICAID |