Basic Information
| Provider Information | |||||||||
| NPI: | 1730121575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANERJEE | ||||||||
| FirstName: | SANJOY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2109 HUGHES DR | ||||||||
| Address2: | SUITE 860 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192917010 | ||||||||
| FaxNumber: | 4194796917 | ||||||||
| Practice Location | |||||||||
| Address1: | 2109 HUGHES DR | ||||||||
| Address2: | SUITE 860 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192917010 | ||||||||
| FaxNumber: | 4194796917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | 35.087838 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 46880 | 01 | HEALTH PLAN OF MI | OTHER | 734534 | 01 | OH | BUCKEYE COMMUNITY HEALTH | OTHER | 2665692 | 05 | OH | MEDICAID | 5202134 | 05 | MI | MEDICAID | 2665692 | 01 | OH | BCMH | OTHER | 06120 | 01 | OH | PARAMOUNT | OTHER | 7978181 | 01 | OH | AETNA | OTHER | 000000521494 | 01 | OH | ANTHEM | OTHER |