Provider Demographics
NPI:1114088960
Name:RAYMOND A BANNAN
Entity Type:Organization
Organization Name:RAYMOND A BANNAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-676-1121
Mailing Address - Street 1:3372 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:OH
Mailing Address - Zip Code:43906-1523
Mailing Address - Country:US
Mailing Address - Phone:740-676-1121
Mailing Address - Fax:
Practice Address - Street 1:3372 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:OH
Practice Address - Zip Code:43906-1523
Practice Address - Country:US
Practice Address - Phone:740-676-1121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 054143207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH180012369OtherRAILROAD MEDICARE
OH0819930Medicaid
OHDG5587OtherRAILROAD MEDICARE GROUP
OHE01756Medicare UPIN
OH9326772Medicare ID - Type Unspecified