1922252352 NPI number — MR. TIMOTHY LEE CUNNINGHAM

Table of content: (NPI 1558969915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922252352 NPI number — MR. TIMOTHY LEE CUNNINGHAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUNNINGHAM
Provider First Name:
TIMOTHY
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1922252352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 E MAIN ST
Provider Second Line Business Mailing Address:
4TH FLOOR ADMINISTRATION
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06702-2310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-574-9000
Provider Business Mailing Address Fax Number:
203-574-9006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
141 E MAIN ST
Provider Second Line Business Practice Location Address:
WATERBURY CLINICAL SERVICES
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06702-2310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-756-7287
Provider Business Practice Location Address Fax Number:
203-236-0122
Provider Enumeration Date:
11/12/2008

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: 101YA0400X , with the licence number:  000073 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 060669107 . This is a "UBH/CONNECTICARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH/OPTUM BEHAVIORAL HEALTH WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 008037428 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 060669107 . This is a "ANTHEM BCBS OF CT WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4853958 . This is a "CIGNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9790693 . This is a "AETNA BEHAVIORAL HEALTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH/LIBERTY FREEDOM WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 390290 . This is a "MHN-TRICARENORTH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 11241824 . This is a "CAQH" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 390290 . This is a "MHN- MANAGED HEALTH NETWORK" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: D339123 WATERBURY . This is a "BEACON HEALTH STRATEGIES WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "HEALTHYCT WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 060669107 . This is a "UBH/UNITED HEALTHCARE WELLMORE GRP/FACILITY" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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