Provider Demographics
NPI:1134240104
Name:BANNISTER, THOMAS WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:WILLIAM
Last Name:BANNISTER
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:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7305
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:9 MEDICAL PARK
Practice Address - Street 2:SUITE 530
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6859
Practice Address - Country:US
Practice Address - Phone:803-434-4603
Practice Address - Fax:803-434-3866
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23586208000000X, 2080P0203X
FL996212080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC235862Medicaid
SC235862Medicaid