Basic Information
| Provider Information | |||||||||
| NPI: | 1154508075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANKS | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BANKS | ||||||||
| OtherFirstName: | JOE | ||||||||
| OtherMiddleName: | EDWARD | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | II | ||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 333 W HAMPTON DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462083632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743040428 | ||||||||
| FaxNumber: | 3176027531 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 E SOUTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462252121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179548659 | ||||||||
| FaxNumber: | 3177810470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02003296A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000567706 | 01 | IN | BCBS | OTHER | 000000665120 | 01 | IN | ANTHEM FMC | OTHER | 200906930 | 05 | IN | MEDICAID |