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General NPI Number Information
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NPI Number | 1205818929
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Entity Type | Individual
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Provider Name | KENNETH J BANASIAK MD
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Gender | Male
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Dates
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Enumeration Date | 11/17/2005
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Last Update Date | 09/09/2022
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Provider Practice Location Address
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Address Line | 282 WASHINGTON ST
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City | HARTFORD
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State | CT
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Zip | 06106-3322
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Country | US
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Telephone | 860-545-9850
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Fax | 860-545-8812
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Provider Business Mailing Address
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Address Line | 301 US ROUTE 1 BUILDING C
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City | SCARBOROUGH
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State | ME
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Zip | 04074-7609
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Country | US
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Telephone | 207-396-8600
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Fax | 207-396-8632
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0203X
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Taxonomy Name | Pediatric Critical Care Medicine Physician
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License Number | 035451
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 2080P0203X
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Taxonomy Name | Pediatric Critical Care Medicine Physician
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License Number | 017898
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License Number State | ME
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