Provider Demographics
NPI:1912959362
Name:BANNON, RICHARD BRUCE (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRUCE
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 1:391 GLENN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:PACOLET
Mailing Address - State:SC
Mailing Address - Zip Code:29372-2417
Mailing Address - Country:US
Mailing Address - Phone:864-474-3013
Mailing Address - Fax:864-474-1501
Practice Address - Street 1:391 GLENN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:PACOLET
Practice Address - State:SC
Practice Address - Zip Code:29372-2417
Practice Address - Country:US
Practice Address - Phone:864-474-3013
Practice Address - Fax:864-474-1501
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00386835OtherMEDICARE RAILROAD PTAN#
SC072398Medicaid
SC5878670002Medicare NSC
GAP00386835OtherMEDICARE RAILROAD PTAN#
SCB925365305Medicare PIN
SCB925368688Medicare PIN