1528038312 NPI number — DR. FRED KELLY CUNNINGHAM MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528038312 NPI number — DR. FRED KELLY CUNNINGHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUNNINGHAM
Provider First Name:
FRED
Provider Middle Name:
KELLY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528038312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 BEE CAVES RD STE 260
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST LAKE HILLS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78746-5226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-410-0767
Provider Business Mailing Address Fax Number:
512-649-7402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 BEE CAVE ROAD BLDG I
Provider Second Line Business Practice Location Address:
STE 260
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78746-5226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-410-0767
Provider Business Practice Location Address Fax Number:
512-649-7402
Provider Enumeration Date:
01/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  G4944 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1278600001 . This is a "MEDICARE SUPPLIER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 131598805 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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