Provider Demographics
NPI:1013395235
Name:BANNISTER INTERNAL MEDICINE CLINIC
Entity Type:Organization
Organization Name:BANNISTER INTERNAL MEDICINE CLINIC
Other - Org Name:BANNISTER INTERNAL MEDICINE CLINIC, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FATIMA
Authorized Official - Middle Name:H
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:816-599-6317
Mailing Address - Street 1:9520 JAMES A REED RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64134-1689
Mailing Address - Country:US
Mailing Address - Phone:816-599-6317
Mailing Address - Fax:816-599-6319
Practice Address - Street 1:9520 JAMES A REED RD
Practice Address - Street 2:SUITE B
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64134-1689
Practice Address - Country:US
Practice Address - Phone:816-599-6317
Practice Address - Fax:816-599-6319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010019768261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1881914034Medicaid