Provider Demographics
NPI:1366533952
Name:CHAIM BANJO MD PHD PA
Entity type:Organization
Organization Name:CHAIM BANJO MD PHD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BANJO
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:972-686-7947
Mailing Address - Street 1:718 W MOORE AVE
Mailing Address - Street 2:101
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160
Mailing Address - Country:US
Mailing Address - Phone:972-551-1900
Mailing Address - Fax:
Practice Address - Street 1:718 W MOORE AVE
Practice Address - Street 2:101
Practice Address - City:TERRELL
Practice Address - State:TX
Practice Address - Zip Code:75160
Practice Address - Country:US
Practice Address - Phone:972-551-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4442207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109453402Medicaid
TX85A011OtherRENDERING PROVIDER
TXOOFT68Medicare PIN
TX85A011OtherRENDERING PROVIDER
TXTXB115160Medicare PIN
TXTXB115159Medicare PIN
C13129Medicare UPIN
TX109453402Medicaid