Basic Information
| Provider Information | |||||||||
| NPI: | 1447312160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANIK | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | ROST | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O., MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 WASHINGTON AVE SE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554142924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128840301 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2450 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122738700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2006 | ||||||||
| LastUpdateDate: | 01/24/2014 | ||||||||
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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 | 2084P0800X | LP00915 | RI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 57168 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 107219 | 01 | MN | MINNESOTA MEDICAL LICENSE | OTHER | 1447312160 | 01 | MN | BLUECROSS/ BLUESHIELD OF MN | OTHER |