Healthcare Provider Details

I. General information

NPI: 1487659801
Provider Name (Legal Business Name): SCOTT J. BANNING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12655 WARWICK BLVD
NEWPORT NEWS VA
23606-2501
US

IV. Provider business mailing address

860 OMNI BLVD STE 101
NEWPORT NEWS VA
23606-4430
US

V. Phone/Fax

Practice location:
  • Phone: 757-595-9880
  • Fax: 757-595-0362
Mailing address:
  • Phone: 757-232-8777
  • Fax: 757-232-8866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101048645
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: