Provider Demographics
NPI:1487648408
Name:BANOZIC, RICHARD M (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:BANOZIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6847 N. CHESTNUT STREET
Mailing Address - Street 2:SUITE 310
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266
Mailing Address - Country:US
Mailing Address - Phone:330-296-2819
Mailing Address - Fax:330-297-9503
Practice Address - Street 1:6847 N. CHESTNUT STREET
Practice Address - Street 2:SUITE 310
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266
Practice Address - Country:US
Practice Address - Phone:330-296-2819
Practice Address - Fax:330-297-9503
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35067230207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0985939Medicaid
OH1770896268OtherTALLMADGE INTERNAL MEDICINE SPECIALISTS
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE GROUP #
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE GROUP #