Healthcare Provider Details

I. General information

NPI: 1891713103
Provider Name (Legal Business Name): MARY E. BANE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 N MAIN ST
ENGLEWOOD OH
45415-1180
US

IV. Provider business mailing address

9000 N. MAIN ST. STE. 321
DAYTON OH
45429-1185
US

V. Phone/Fax

Practice location:
  • Phone: 937-433-7536
  • Fax: 937-433-9612
Mailing address:
  • Phone: 937-836-0500
  • Fax: 937-836-0636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35080354B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: