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NPI Code Detail

MEDICARE: HEATHER E BANIAK PT

MEDICARE: HEATHER E BANIAK PT
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
1225100000XPhysical Therapist2009020457MO

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P01170364OTHERMORAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
212480681OTHERMOCAQH

General Provider Information

NPI Number : 1316177637
Entity Type Code : Individual
Provider Name (Legal Business Name) : HEATHER E BANIAK PT
Provider Business Mailing Address
First Line : 607 DEWEY AVE NW
Second Line : STE 300
City : GRAND RAPIDS
State : MI
Zip : 49504-7335
Country : US
Telephone Number : 616-356-5000
Fax Number : 636-356-5001
Provider Business Practice Location Address
First Line : 2454 WEST CLAY
Second Line :
City : ST CHARLES
State : MO
Zip : 63301-2548
Country : US
Telephone Number : 636-949-3926
Fax Number : 636-949-3928
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/21/2009
Last Update Date : 08/23/2016

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Directions to “ HEATHER E BANIAK PT” Practice Location

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