Provider Demographics
NPI:1639319411
Name:SUDESH BANAJI MD PLLC
Entity Type:Organization
Organization Name:SUDESH BANAJI MD PLLC
Other - Org Name:EARLE FAMILY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SUDESH
Authorized Official - Middle Name:
Authorized Official - Last Name:BANAJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-792-8825
Mailing Address - Street 1:332 E COOK ST
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-2830
Mailing Address - Country:US
Mailing Address - Phone:870-630-2233
Mailing Address - Fax:870-630-2224
Practice Address - Street 1:1605 SECOND STREET
Practice Address - Street 2:
Practice Address - City:EARLE
Practice Address - State:AR
Practice Address - Zip Code:72331-1634
Practice Address - Country:US
Practice Address - Phone:870-792-8825
Practice Address - Fax:870-792-8834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X
ARE2405261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty