Provider Demographics
NPI:1417094061
Name:BANNER, KATHRYN K (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:K
Last Name:BANNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 HOPE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-1126
Mailing Address - Country:US
Mailing Address - Phone:401-247-0610
Mailing Address - Fax:401-253-3131
Practice Address - Street 1:1180 HOPE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-1126
Practice Address - Country:US
Practice Address - Phone:401-247-0610
Practice Address - Fax:401-253-3131
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD12307207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI32535OtherNEIGHBORHOOD HEALTH PLAN
RI0000032662OtherB/S
RI1417094Medicaid
RI414090OtherBCHIP
RIAA89360OtherHARVARD PILGRIM
RI050340866OtherUHC
RI0000032662OtherB/S
RI050340866OtherUHC