Basic Information
| Provider Information | |||||||||
| NPI: | 1942265756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANNER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 406 E ELM ST | ||||||||
| Address2: | PO BOX 879 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843971 | ||||||||
| FaxNumber: | 9895843729 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 E ELM ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895843971 | ||||||||
| FaxNumber: | 9895843729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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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 | 207ZP0105X | 5101011192 | MI | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2675872 | 05 | MI | MEDICAID |