Basic Information
| Provider Information | |||||||||
| NPI: | 1336218031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANISTER | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636961 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815130 | ||||||||
| FaxNumber: | 5139815015 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 MEDICAL CENTER DR | ||||||||
| Address2: | STE 205 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704414462 | ||||||||
| FaxNumber: | 2704414461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 11/25/2014 | ||||||||
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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 | 208600000X | 32967 | KY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 64027147 | 05 | KY | MEDICAID |