Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | CH4858 | FL |
NPI | 1174590095 |
---|---|
Provider Name | Dr. John Ramon Banacki |
First Address | Palm Harbor, FL 34683-2633 |
Second Address | Palm Harbor, FL 34683-2633 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/03/2006 |
Last Update Date | 24/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
74889 | MEDICARE GROUP ID # (01) | FL |
T55025 | (02) | FL |