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General NPI Number Information
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NPI Number | 1801277363
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Entity Type | Individual
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Provider Name | JEFFREY O'BANNER MD
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Gender | Male
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Dates
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Enumeration Date | 06/10/2015
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Last Update Date | 09/21/2025
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Provider Practice Location Address
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Address Line | 4250 BETHEL RD
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-8737
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Country | US
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Telephone | 662-932-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 180 S 3RD ST SUITE 300
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City | BELLEVILLE
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State | IL
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Zip | 62220-1952
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Country | US
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Telephone | 618-333-5480
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Fax | 618-222-4790
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 31799
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 31799
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License Number State | MS
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