Healthcare Provider Details

I. General information

NPI: 1770578460
Provider Name (Legal Business Name): SEVAG BANANIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 06/26/2021
Certification Date: 06/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10810 CONNECTICUT AVE KAISER PERMANENTE KENSINGTON MEDICAL CENTER
KENSINGTON MD
20895-2138
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: 301-929-7100
  • Fax:
Mailing address:
  • Phone: 301-816-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0071905
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberE4956
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberD0071905
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: