Basic Information
| Provider Information | |||||||||
| NPI: | 1962479451 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANEZ | ||||||||
| FirstName: | MONICO | ||||||||
| MiddleName: | PETER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 HIGHWAY 45 BYP | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383054436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608759 | ||||||||
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| Practice Location | |||||||||
| Address1: | 620 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608759 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 27436 | MS | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 35303 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3889132 | 05 | TN | MEDICAID | 4070560 | 01 | BCBS | OTHER | P00077531 | 01 | RR MEDICARE | OTHER |