Healthcare Provider Details

I. General information

NPI: 1114910353
Provider Name (Legal Business Name): JOHN S BANAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date: 03/27/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

2570 24TH ST SUITE 122
ROCK ISLAND IL
61201-5394
US

IV. Provider business mailing address

2570 24TH ST STE. 122
ROCK ISLAND IL
61201-5394
US

V. Phone/Fax

Practice location:
  • Phone: 309-779-3868
  • Fax: 309-779-3139
Mailing address:
  • Phone: 309-779-3868
  • Fax: 309-779-3199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036-081701
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: