MEDICARE: DEBABRATA BANERJI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	R6523	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548268014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBABRATA BANERJI M.D.

Provider Business Mailing Address
First Line	:	83 PROGRESS PKWY
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043-3701
Country	:	US
Telephone Number	:	314-434-8174
Fax Number	:	314-434-8706

Provider Business Practice Location Address
First Line	:	83 PROGRESS PKWY
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043
Country	:	US
Telephone Number	:	314-434-8174
Fax Number	:	314-434-8706

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	11/21/2011

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