Provider Demographics
NPI:1922058403
Name:BANNISTER, CAROLYN F (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:F
Last Name:BANNISTER
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 1:2540 WINDY HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8605
Mailing Address - Country:US
Mailing Address - Phone:470-644-1274
Mailing Address - Fax:470-644-1119
Practice Address - Street 1:2540 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8605
Practice Address - Country:US
Practice Address - Phone:470-644-1274
Practice Address - Fax:470-644-1119
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121972207LP3000X
GA029840207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000463119NMedicaid
FL013892600Medicaid
FL013892600Medicaid