Provider Demographics
NPI:1932171857
Name:BANNOW, THOMAS R (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:BANNOW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 S GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2960
Mailing Address - Country:US
Mailing Address - Phone:231-946-8686
Mailing Address - Fax:231-935-1455
Practice Address - Street 1:201 S GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2960
Practice Address - Country:US
Practice Address - Phone:231-946-8686
Practice Address - Fax:231-935-1455
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITB006643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI112773461Medicaid
MI5120235OtherAETNA
MI080186042OtherRR MEDICARE
MI0852834554OtherBLUE SHIELD
MI136442OtherCARE CHOICE
MIE26799OtherPRIORITY
MI0852834554OtherBLUE SHIELD
MIE26799Medicare UPIN