Provider Demographics
NPI:1114910353
Name:BANAS, JOHN S (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:BANAS
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 1:2570 24TH ST
Mailing Address - Street 2:STE. 122
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5394
Mailing Address - Country:US
Mailing Address - Phone:309-779-3868
Mailing Address - Fax:309-779-3199
Practice Address - Street 1:2570 24TH ST
Practice Address - Street 2:SUITE 122
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5394
Practice Address - Country:US
Practice Address - Phone:309-779-3868
Practice Address - Fax:309-779-3139
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2012-05-21
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
IL036-081701207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1114910353Medicaid
IA0922052Medicaid
IL036081701Medicaid
IL036081701Medicaid
ILB51345Medicare UPIN
IL200715030Medicare PIN
IA0922052Medicaid