Healthcare Provider Details

I. General information

NPI: 1104033786
Provider Name (Legal Business Name): BHOLA N. BANIK, M.D., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1097 OLD COUNTRY RD SUITE 103
PLAINVIEW NY
11803-6505
US

IV. Provider business mailing address

1097 OLD COUNTRY RD SUITE 103
PLAINVIEW NY
11803-6505
US

V. Phone/Fax

Practice location:
  • Phone: 516-931-3131
  • Fax: 516-931-3140
Mailing address:
  • Phone: 516-931-3131
  • Fax: 516-931-3140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number119027
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00222380
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: DR. BHOLA N. BANIK
Title or Position: OWNER
Credential: MD
Phone: 516-931-3131