Provider Demographics
NPI:1881677953
Name:BANEVICIUTE, LINA (MD)
Entity Type:Individual
Prefix:DR
First Name:LINA
Middle Name:
Last Name:BANEVICIUTE
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 1309
Mailing Address - Street 2:MS21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-1309
Mailing Address - Country:US
Mailing Address - Phone:952-993-2400
Mailing Address - Fax:
Practice Address - Street 1:5320 HYLAND GREENS DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-3934
Practice Address - Country:US
Practice Address - Phone:952-993-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112257207R00000X
MN61993207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112257Medicaid
IL036112257Medicaid
ILK21571Medicare ID - Type UnspecifiedMEDICARE