Provider Demographics
NPI:1962443739
Name:KOROMA, BANIO P (MD)
Entity Type:Individual
Prefix:
First Name:BANIO
Middle Name:P
Last Name:KOROMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 N ELSTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-5811
Mailing Address - Country:US
Mailing Address - Phone:773-751-7200
Mailing Address - Fax:773-583-4295
Practice Address - Street 1:3319 N ELSTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5811
Practice Address - Country:US
Practice Address - Phone:773-751-7200
Practice Address - Fax:773-583-4295
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-069938207QG0300X, 207RG0300X
IN01048271A207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213131Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER