Basic Information
| Provider Information | |||||||||
| NPI: | 1760468110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANISH | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 33369 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282333369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043648100 | ||||||||
| FaxNumber: | 7043652073 | ||||||||
| Practice Location | |||||||||
| Address1: | 10512 PARK RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045423631 | ||||||||
| FaxNumber: | 7045423646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 19490 | SC | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 2015-00687 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 76051 | 01 | SC | MEDCOST | OTHER | 770001362 | 01 | SC | BANKERS LIFE AND CASUALTY | OTHER | 1760468110 | 05 | NC | MEDICAID | T37948 | 05 | SC | MEDICAID | 9645030 | 01 | SC | GHI | OTHER | 620108 | 01 | SC | SELECT HEALTH | OTHER | 9377345 | 01 | SC | CIGNA | OTHER |