Provider Demographics
NPI:1285687970
Name:BANACH, TIMOTHY (PT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:BANACH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-3204
Mailing Address - Country:US
Mailing Address - Phone:216-595-8290
Mailing Address - Fax:216-621-5479
Practice Address - Street 1:27040 CEDAR RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-1115
Practice Address - Country:US
Practice Address - Phone:216-595-8290
Practice Address - Fax:216-621-5479
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT09551225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBA4100462Medicare PIN
OHBA4100461Medicare PIN