Provider Demographics
NPI:1700370871
Name:BANKS, EDWARD MARTIN JR (BS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:MARTIN
Last Name:BANKS
Suffix:JR
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 NE BRAILLE PL
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-5345
Mailing Address - Country:US
Mailing Address - Phone:772-320-0792
Mailing Address - Fax:
Practice Address - Street 1:1601 NE BRAILLE PL
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-5345
Practice Address - Country:US
Practice Address - Phone:772-320-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL912987100Medicaid