Basic Information
| Provider Information | |||||||||
| NPI: | 1518953942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANNACH | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023345929 | ||||||||
| FaxNumber: | 8024871051 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023345929 | ||||||||
| FaxNumber: | 8024871051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 042-0010849 | VT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1011209 | 05 | VT | MEDICAID | 00068445 | 01 | VT | BLUECROSSBLUESHIELD | OTHER |