Provider Demographics
NPI:1326563966
Name:BANSA MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:BANSA MEDICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BANSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-933-0872
Mailing Address - Street 1:1609 SIBLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2217
Mailing Address - Country:US
Mailing Address - Phone:708-933-0872
Mailing Address - Fax:
Practice Address - Street 1:1609 SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-2217
Practice Address - Country:US
Practice Address - Phone:708-933-0872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053245207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053245Medicaid