Healthcare Provider Details

I. General information

NPI: 1699088203
Provider Name (Legal Business Name): SHRUTEE BANIYA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W JACKSON ST
CARBONDALE IL
62901-1462
US

IV. Provider business mailing address

405 W JACKSON ST
CARBONDALE IL
62901-1462
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-0271
  • Fax: 618-529-0479
Mailing address:
  • Phone: 618-549-0721
  • Fax: 618-529-0479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036135422
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036.135422
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: