Provider Demographics
NPI:1629316070
Name:BANYAN2
Entity Type:Organization
Organization Name:BANYAN2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-663-5696
Mailing Address - Street 1:6619 S DIXIE HWY
Mailing Address - Street 2:SUITE 229
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-7919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6175 NW 153RD ST
Practice Address - Street 2:SUITE 332
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2435
Practice Address - Country:US
Practice Address - Phone:305-663-5696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service