Provider Demographics
NPI:1841351400
Name:RAYMOND A BANNAN
Entity type:Organization
Organization Name:RAYMOND A BANNAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-242-9245
Mailing Address - Street 1:2101 JACOB ST. SUITE 201
Mailing Address - Street 2:VALLEY PROF. CENTER SOUTH
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3800
Mailing Address - Country:US
Mailing Address - Phone:304-242-9245
Mailing Address - Fax:304-242-6870
Practice Address - Street 1:2101 JACOB ST. SUITE 201
Practice Address - Street 2:VALLEY PROF. CENTER SOUTH
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3800
Practice Address - Country:US
Practice Address - Phone:304-242-9245
Practice Address - Fax:304-242-6870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16474207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV180012368OtherRAILROAD MEDICARE
WVDG8768OtherRAILROAD MEDICARE GRP
WV009548000Medicaid
WVDG8768OtherRAILROAD MEDICARE GRP
WV009548000Medicaid
WV0925920001Medicare NSC