Healthcare Provider Details

I. General information

NPI: 1639373699
Provider Name (Legal Business Name): JENNIFER MARISSA BANAYAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E SUPERIOR ST
CHICAGO IL
60611
US

IV. Provider business mailing address

680 N LAKE SHORE DR
CHICAGO IL
60611-4546
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-2000
  • Fax:
Mailing address:
  • Phone: 312-695-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036.122189
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: