Basic Information
| Provider Information | |||||||||
| NPI: | 1700080561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUNNINGHAM | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH STREET | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217561 | ||||||||
| FaxNumber: | 3173556096 | ||||||||
| Practice Location | |||||||||
| Address1: | 7165 CLEARVISTA WAY | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462564621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217804 | ||||||||
| FaxNumber: | 3176217275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | R836 | AZ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 02003893A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 000000749766 | 01 | IN | ANTHEM BCBS | OTHER | 100270530 | 05 | IN | MEDICAID | 201045350 | 05 | IN | MEDICAID | P01191797 | 01 | IN | RR MEDICARE PTAN | OTHER | 000000750186 | 01 | IN | ANTHEM BCBS | OTHER |