Healthcare Provider Details

I. General information

NPI: 1528046349
Provider Name (Legal Business Name): STEPHEN MICHAEL BANE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 OPITZ BLVD SUITE 340
WOODBRIDGE VA
22191-3362
US

IV. Provider business mailing address

207 JEFFERSON ST
ALEXANDRIA VA
22314-4323
US

V. Phone/Fax

Practice location:
  • Phone: 703-878-0777
  • Fax: 703-583-1777
Mailing address:
  • Phone: 703-878-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101055871
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number0101055871
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: