Basic Information
| Provider Information | |||||||||
| NPI: | 1083918361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANASZAK | ||||||||
| FirstName: | TERRANCE | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 335 GLESSNER AVE RM 325E | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195202495 | ||||||||
| FaxNumber: | 4195202496 | ||||||||
| Practice Location | |||||||||
| Address1: | 4343 ALL SEASONS DR STE 160 | ||||||||
| Address2: | |||||||||
| City: | HILLIARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145412676 | ||||||||
| FaxNumber: | 6145412678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2010 | ||||||||
| LastUpdateDate: | 08/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 58003673 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0106005 | 05 | OH | MEDICAID |