Provider Demographics
NPI:1366498198
Name:BANNON, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:BANNON
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Gender:M
Credentials:MD
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Mailing Address - Street 1:746 JEFFERSON AVE
Mailing Address - Street 2:THE WOUND CENTER
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510-1921
Mailing Address - Country:US
Mailing Address - Phone:570-340-5824
Mailing Address - Fax:570-340-5844
Practice Address - Street 1:746 JEFFERSON AVE
Practice Address - Street 2:THE WOUND CENTER
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1624
Practice Address - Country:US
Practice Address - Phone:570-340-5824
Practice Address - Fax:570-340-5844
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-08-23
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Provider Licenses
StateLicense IDTaxonomies
PAMD028552L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB33925Medicare UPIN