Provider Demographics
NPI:1891713103
Name:BANE, MARY E (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
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 1:9000 N. MAIN ST.
Mailing Address - Street 2:STE. 321
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1185
Mailing Address - Country:US
Mailing Address - Phone:937-836-0500
Mailing Address - Fax:937-836-0636
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-433-7536
Practice Address - Fax:937-433-9612
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080354B207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH070017198OtherRAILROAD MEDICARE
OH3109647743A22OtherANTHEM BLUE SHIELD
OHD80354OtherHUMANA CHOICE CARE
OHH66213Medicare UPIN
OHBA4088101Medicare PIN