Provider Demographics
NPI:1679707111
Name:BANE, HEATHER ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELAINE
Last Name:BANE
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 S. TRYON ST.
Practice Address - Street 2:STE 201
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4958
Practice Address - Country:US
Practice Address - Phone:704-316-3000
Practice Address - Fax:704-316-3001
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-02057207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2570Medicaid
NC1679707111Medicaid
NCNCQ708AMedicare PIN