Basic Information
| Provider Information | |||||||||
| NPI: | 1891882536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANERIAN | ||||||||
| FirstName: | KIRK | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 LUDINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | ESCANABA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498291300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067863311 | ||||||||
| FaxNumber: | 9067890941 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 LUDINGTON STREET | ||||||||
| Address2: | |||||||||
| City: | ESCANABA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498291300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067863311 | ||||||||
| FaxNumber: | 9067890941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | ME76335 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | ME76335 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 4301048787 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 016623400 | 05 | FL | MEDICAID | 495680 | 01 | MI | HAP | OTHER | 0Q26008 | 01 | MI | BCN OF MICHIGAN | OTHER | 4550607 | 05 | MI | MEDICAID | 371664910 | 01 | HEALTH NET FED SERVICES | OTHER | 0Q26008 | 01 | MI | BCBS OF MICHIGAN | OTHER | 1006439 | 01 | MI | MCCLAREN | OTHER | SJ820005 | 01 | MI | M-CARE | OTHER | 0Q26008054 | 01 | FEDERAL BLACK LUNG | OTHER | P00067927 | 01 | RR MEDICARE | OTHER |