Healthcare Provider Details

I. General information

NPI: 1801087044
Provider Name (Legal Business Name): JAMES C BANICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9348 GRAND CORDERA PKWY STE 160
COLORADO SPRINGS CO
80924-7023
US

IV. Provider business mailing address

9348 GRAND CORDERA PKWY STE 160
COLORADO SPRINGS CO
80924-7023
US

V. Phone/Fax

Practice location:
  • Phone: 719-355-1585
  • Fax: 719-623-2983
Mailing address:
  • Phone: 719-355-1585
  • Fax: 719-623-2983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberDR0059047
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: