Provider Demographics
NPI:1528083474
Name:BANAIE MEDICAL CORPORATION
Entity type:Organization
Organization Name:BANAIE MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:BANAIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-469-5400
Mailing Address - Street 1:8860 CENTER DRIVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-469-5400
Mailing Address - Fax:619-464-1311
Practice Address - Street 1:8860 CENTER DRIVE
Practice Address - Street 2:SUITE 420
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-469-5400
Practice Address - Fax:619-464-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A873080Medicaid
CAW17381OtherPTAN
CAW17381OtherPTAN