Provider Demographics
NPI:1144202284
Name:BANACH, WARREN R (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:R
Last Name:BANACH
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 1:101 E BRUNSON ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2526
Mailing Address - Country:US
Mailing Address - Phone:334-393-0737
Mailing Address - Fax:334-393-0914
Practice Address - Street 1:101 E BRUNSON ST
Practice Address - Street 2:SUITE 310
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2526
Practice Address - Country:US
Practice Address - Phone:334-393-0737
Practice Address - Fax:334-393-0914
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11333207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL09946540Medicaid
ALC74623Medicare UPIN
AL051550152Medicare ID - Type Unspecified