Basic Information
| Provider Information | |||||||||
| NPI: | 1871709964 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANERJEE | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | SWATI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13719 LORAIN AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441113439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163073005 | ||||||||
| FaxNumber: | 2167105360 | ||||||||
| Practice Location | |||||||||
| Address1: | 13719 LORAIN AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441113439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2163073005 | ||||||||
| FaxNumber: | 2167105360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35126030 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0132113 | 05 | OH | MEDICAID |