=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992799498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS CLARK BANEVER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 RETREAT AVE SUITE 808
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-249-9189
-----------------------------------------------------
Fax | 860-249-9180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 RETREAT AVE SUITE 808
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-249-9189
-----------------------------------------------------
Fax | 860-249-9180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 016245
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------