Basic Information
| Provider Information | |||||||||
| NPI: | 1912068768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANNOUT | ||||||||
| FirstName: | FIRAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 S MAIN ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | HINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313134353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128776822 | ||||||||
| FaxNumber: | 9124086781 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 S MAIN ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | HINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313134353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128776822 | ||||||||
| FaxNumber: | 9124086781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 12/04/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 055176 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 649003064B | 05 | GA | MEDICAID |