Provider Demographics
NPI:1215907456
Name:BANNON, KEVIN R (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:BANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE 3600
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6256
Mailing Address - Country:US
Mailing Address - Phone:610-770-1606
Mailing Address - Fax:610-740-0560
Practice Address - Street 1:1200 S CEDAR CREST BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103
Practice Address - Country:US
Practice Address - Phone:610-402-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070875L2085N0700X
PAMD070785L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018060670001Medicaid
PA038663Medicare ID - Type Unspecified
PA0018060670001Medicaid