Provider Demographics
NPI:1730269408
Name:BANAS, ANTONI (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONI
Middle Name:
Last Name:BANAS
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 1:19 HERITAGE DR
Mailing Address - Street 2:STE 209
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1369
Mailing Address - Country:US
Mailing Address - Phone:815-932-3540
Mailing Address - Fax:815-932-3611
Practice Address - Street 1:19 HERITAGE DR
Practice Address - Street 2:STE 209
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1369
Practice Address - Country:US
Practice Address - Phone:815-932-3540
Practice Address - Fax:815-932-3611
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090701208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090701Medicaid
IL651282261Medicaid
F45387Medicare UPIN