Healthcare Provider Details

I. General information

NPI: 1619984523
Provider Name (Legal Business Name): MICHAEL R. BANTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 11/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 MANCHESTER RD STE 150
SAINT LOUIS MO
63131-1743
US

IV. Provider business mailing address

13100 MANCHESTER RD STE 150
SAINT LOUIS MO
63131-1743
US

V. Phone/Fax

Practice location:
  • Phone: 314-692-7886
  • Fax: 314-692-7929
Mailing address:
  • Phone: 314-692-7886
  • Fax: 314-692-7929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR1J81
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberR1J81
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: