Provider Demographics
NPI:1760624704
Name:GARRY G BANKS MD PA
Entity Type:Organization
Organization Name:GARRY G BANKS MD PA
Other - Org Name:GARRY G BANKS MD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:G
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:850-678-7676
Mailing Address - Street 1:552 TWIN CITIES BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1055
Mailing Address - Country:US
Mailing Address - Phone:850-678-7676
Mailing Address - Fax:850-678-8240
Practice Address - Street 1:552 TWIN CITIES BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1055
Practice Address - Country:US
Practice Address - Phone:850-678-7676
Practice Address - Fax:850-678-8240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062947207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF54795Medicare UPIN