Provider Demographics
NPI:1366584294
Name:BURTON BANNER M.D., P.C.
Entity type:Organization
Organization Name:BURTON BANNER M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BURTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-494-6400
Mailing Address - Street 1:2281 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6625
Mailing Address - Country:US
Mailing Address - Phone:718-494-6400
Mailing Address - Fax:718-761-6854
Practice Address - Street 1:2281 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6625
Practice Address - Country:US
Practice Address - Phone:718-494-6400
Practice Address - Fax:718-761-6854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care