1932171857 NPI number — DR. THOMAS R BANNOW D.O.

Table of content: DR. THOMAS R BANNOW D.O. (NPI 1932171857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932171857 NPI number — DR. THOMAS R BANNOW D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANNOW
Provider First Name:
THOMAS
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1932171857
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 S GARFIELD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49686-2960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-946-8686
Provider Business Mailing Address Fax Number:
231-935-1455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 S GARFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49686-2960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-946-8686
Provider Business Practice Location Address Fax Number:
231-935-1455
Provider Enumeration Date:
02/03/2006

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: 207Q00000X , with the licence number:  TB006643 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 112773461 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5120235 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 080186042 . This is a "RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0852834554 . This is a "BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 136442 . This is a "CARE CHOICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: E26799 . This is a "PRIORITY" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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