Basic Information
| Provider Information | |||||||||
| NPI: | 1518920099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CUNNANE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | THERESE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6320 RIVERSIDE PLAZA LN NW STE B | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058436168 | ||||||||
| FaxNumber: | 5057921978 | ||||||||
| Practice Location | |||||||||
| Address1: | 4640 JEFFERSON LN NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871092127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058436168 | ||||||||
| FaxNumber: | 5057921978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 24905 | NE | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | 147803-1 | NY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | 88-149 | NM | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000927695002 | 01 | NY | BC/BS OF WESTERN NEW YORK | OTHER | 00008169 | 05 | NM | MEDICAID | P010147803 | 01 | NY | BLUE CHOICE | OTHER | 5362090 | 01 | NY | AETNA | OTHER | 171575CK | 01 | NY | PREFERRED CARE | OTHER | P00265970 | 01 | NY | RAILROAD | OTHER |