Provider Demographics
NPI:1538129010
Name:BANNISTER, TAMMY L (MD)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:BANNISTER
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 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3656
Mailing Address - Country:US
Mailing Address - Phone:304-691-1100
Mailing Address - Fax:
Practice Address - Street 1:659 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1313
Practice Address - Country:US
Practice Address - Phone:304-736-5247
Practice Address - Fax:304-736-5768
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV18587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2025632Medicaid
KY64941651Medicaid
WV0054648000Medicaid
KY64941651Medicaid
WV0054648000Medicaid