Provider Demographics
NPI:1093710881
Name:BANNEC, ERIC A (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:BANNEC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-3834
Mailing Address - Fax:
Practice Address - Street 1:550 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3239
Practice Address - Country:US
Practice Address - Phone:812-355-3255
Practice Address - Fax:812-333-5978
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043608A208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200023880Medicaid
INM400021603Medicare UPIN
G07098Medicare UPIN
INM400021603Medicare UPIN