Provider Demographics
NPI:1548328875
Name:BANNAN, RAYMOND ANTHONY
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:ANTHONY
Last Name:BANNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WHARTON CIR
Mailing Address - Street 2:STE 120
Mailing Address - City:TRIADELPHIA
Mailing Address - State:WV
Mailing Address - Zip Code:26059-1293
Mailing Address - Country:US
Mailing Address - Phone:304-242-9245
Mailing Address - Fax:304-242-6870
Practice Address - Street 1:2101 JACOB ST. SUITE 201
Practice Address - Street 2:VALLEY PROF CENTER SOUTH
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6390
Practice Address - Country:US
Practice Address - Phone:304-242-9245
Practice Address - Fax:304-242-6870
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16474207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0095458000Medicaid
WVDG8768OtherRAILROAD MEDICARE GROUP
WV180012368OtherRAILROAD MEDICARE
WV180012368OtherRAILROAD MEDICARE
WVE01756Medicare UPIN
WV0925920001Medicare NSC
OH9326772Medicare PIN