Provider Demographics
NPI:1881647501
Name:BANISTER, JODY (MD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:BANISTER
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 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:300 LAFAYETTE AVE SE
Practice Address - Street 2:SUITE 3000
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4650
Practice Address - Country:US
Practice Address - Phone:616-685-6919
Practice Address - Fax:616-685-3063
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076654207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4545680Medicaid
MI4877035Medicaid
MI4529354Medicaid
MI4529345Medicaid
MI4877840Medicaid
MI4529354Medicaid
MIH91043Medicare UPIN
MI4529345Medicaid
MI4877840Medicaid