Provider Demographics
NPI:1245201714
Name:BANER, TERRILL M (MD)
Entity Type:Individual
Prefix:
First Name:TERRILL
Middle Name:M
Last Name:BANER
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 1:600 JOHN DEERE RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6869
Mailing Address - Country:US
Mailing Address - Phone:309-779-4600
Mailing Address - Fax:309-779-4605
Practice Address - Street 1:600 JOHN DEERE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6869
Practice Address - Country:US
Practice Address - Phone:309-779-4600
Practice Address - Fax:309-779-4605
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058643207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08100333OtherBLUE CROSS BLUE SHIELD
IA1245201714Medicaid
ILIL0101OtherJOHN DEERE INSURANCE
IL036058643Medicaid
IL08100333OtherBLUE CROSS BLUE SHIELD
IL200715045Medicare PIN
ILIL0101OtherJOHN DEERE INSURANCE