1285041632 NPI number — DR. MICHAEL THOMAS BANE PHARMD

Table of content: DR. MICHAEL THOMAS BANE PHARMD (NPI 1285041632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285041632 NPI number — DR. MICHAEL THOMAS BANE PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANE
Provider First Name:
MICHAEL
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
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:
1285041632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 W 21ST ST STE 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23517-2365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-278-2577
Provider Business Mailing Address Fax Number:
757-278-2578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13007 WARWICK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23602-8315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-882-1074
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2014

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: 183500000X , with the licence number:  0202213215 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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