Healthcare Provider Details

I. General information

NPI: 1730240920
Provider Name (Legal Business Name): AMY LYNNE BANULIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 05/31/2021
Certification Date: 05/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 PENNSYLVANIA AVE NW WEST END MEDICAL CENTER
WASHINGTON DC
20037-3202
US

IV. Provider business mailing address

2101 E JEFFERSON ST KAISER PERMANENTE MEDICARE ENROLLMENT
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 202-872-7000
  • Fax: 202-872-7212
Mailing address:
  • Phone: 301-816-6424
  • Fax: 301-816-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD63032
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD035425
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: