Provider Demographics
NPI:1639156805
Name:BANNA, AHMAD (MD)
Entity type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:BANNA
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 1:124 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077
Mailing Address - Country:US
Mailing Address - Phone:440-352-4956
Mailing Address - Fax:440-352-0397
Practice Address - Street 1:124 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077
Practice Address - Country:US
Practice Address - Phone:440-352-4956
Practice Address - Fax:440-375-8829
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35045031B207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0452862Medicaid
A79694Medicare UPIN
OH0452862Medicaid