Provider Demographics
NPI:1508941691
Name:BANNER, MARY CHRISTINE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINE
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:PO BOX 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:901 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2722
Practice Address - Country:US
Practice Address - Phone:682-885-1050
Practice Address - Fax:682-885-7572
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK22172084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10011835OtherAMERIGROUP PIN
TX124029OtherSUPERIOR PIN
TX043860808OtherCSHCN
TX1727210OtherFIRSTHEALTH PIN
TX413461OtherPHCS PIN
TX043860807Medicaid
TX00U87ZOtherBCBSTX GRP PIN
TX85381BOtherBCBSTX IND PIN
1750369203OtherGRP NPI NUMBER
F55827Medicare UPIN
TX124029OtherSUPERIOR PIN