Basic Information
| Provider Information | |||||||||
| NPI: | 1649231366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANNERMAN | ||||||||
| FirstName: | ALFRED | ||||||||
| MiddleName: | CLAYTON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 180 SALEM ROAD | ||||||||
| Address2: | |||||||||
| City: | WESTBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169973269 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8900 VAN WYCK EXPRESSWAY | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182067089 | ||||||||
| FaxNumber: | 7182067055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 11/25/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 111142 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 14071762 | 05 | CO | MEDICAID | 42551056 | 05 | NM | MEDICAID | 084255 | 05 | AZ | MEDICAID |