MEDICARE: DR. MARDI GRAS NANYONGO ETCHI-BANYI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302047702	MI
2	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1154673150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARDI GRAS NANYONGO ETCHI-BANYI

Provider Business Mailing Address
First Line	:	9766 ROSEHILL RD APT I51
Second Line	:
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49103-2221
Country	:	US
Telephone Number	:	301-377-6096
Fax Number	:	269-473-2566

Provider Business Practice Location Address
First Line	:	612 SAINT JOSEPH AVE
Second Line	:
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49103-1603
Country	:	US
Telephone Number	:	301-377-6096
Fax Number	:	269-473-2566

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2012
Last Update Date	:	04/17/2019

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