Basic Information
Provider Information | |||||||||
NPI: | 1184008088 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BANNISTER OPERATIONS ASSOC LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BANNISTER CENTER FOR REHABILITATION AND HEALTHCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4770 WHITE PLAINS RD | ||||||||
Address2: |   | ||||||||
City: | BRONX | ||||||||
State: | NY | ||||||||
PostalCode: | 104701104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7189319700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 135 DODGE ST | ||||||||
Address2: | STREET | ||||||||
City: | PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029072210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4015219600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/10/2015 | ||||||||
LastUpdateDate: | 08/11/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAGLER | ||||||||
AuthorizedOfficialFirstName: | JONATHON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
AuthorizedOfficialTelephone: | 7189319700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 4105038 | 05 | RI |   | MEDICAID | 5005-0 | 01 | RI | BLUE CROSS | OTHER |