Provider Demographics
NPI:1093742215
Name:BANNING, BRUCE C JR (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:C
Last Name:BANNING
Suffix:JR
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:PO BOX 13808
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24037-3808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 ARH LANE
Practice Address - Street 2:
Practice Address - City:LOW MOOR
Practice Address - State:VA
Practice Address - Zip Code:24457
Practice Address - Country:US
Practice Address - Phone:540-862-6287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010420662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7212526Medicaid
VAE45213Medicare UPIN