MEDICARE: BRUCE BANIAS MD LLC

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	207V00000X	Obstetrics & Gynecology Physician	3562520C	OH
2	207V00000X	Obstetrics & Gynecology Physician	35052271	OH

General Provider Information

NPI Number	:	1699966325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUCE BANIAS MD LLC

Provider Business Mailing Address
First Line	:	3075 GOVERNORS PLACE BLVD
Second Line	:	SUITE 210
City	:	DAYTON
State	:	OH
Zip	:	45409-1323
Country	:	US
Telephone Number	:	937-293-5200
Fax Number	:	937-424-5925

Provider Business Practice Location Address
First Line	:	3075 GOVERNORS PLACE BLVD
Second Line	:	SUITE 210
City	:	DAYTON
State	:	OH
Zip	:	45409-1323
Country	:	US
Telephone Number	:	937-293-5200
Fax Number	:	937-424-5925

Authorized Official
Title or Position	:	PHYSICIAN BUSINESS OWNER
Name	:	DR. BRUCE BLAND BANIAS
Credential	:	MD
Telephone Number	:	932-293-5200

Provider Enumeration Date	:	08/07/2007
Last Update Date	:	08/07/2007

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