Basic Information
| Provider Information | |||||||||
| NPI: | 1346258985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUNNANE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 CHESTNUT ST | ||||||||
| Address2: | 14TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191064404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159559655 | ||||||||
| FaxNumber: | 2159552420 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 LOCUST ST | ||||||||
| Address2: | SUITE 521 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191076731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155037822 | ||||||||
| FaxNumber: | 2155034817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | MD009345E | PA | N | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | MD009345E | PA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 8031908 | 05 | NJ | MEDICAID | 00954065 | 05 | PA | MEDICAID |