Provider Demographics
NPI:1639479835
Name:BANACH, RYAN (MD CCFP)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:BANACH
Suffix:
Gender:M
Credentials:MD CCFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:666 W END AVE
Mailing Address - Street 2:4R
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7357
Mailing Address - Country:US
Mailing Address - Phone:917-463-3767
Mailing Address - Fax:
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2574
Practice Address - Country:US
Practice Address - Phone:917-463-3767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine