Provider Demographics
NPI:1962103960
Name:BANE MEDICAL MANAGEMENT LLC
Entity type:Organization
Organization Name:BANE MEDICAL MANAGEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-820-0057
Mailing Address - Street 1:118 HIDDEN HILL CV
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-1000
Mailing Address - Country:US
Mailing Address - Phone:845-820-0057
Mailing Address - Fax:
Practice Address - Street 1:415 S LINDELL ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-2442
Practice Address - Country:US
Practice Address - Phone:731-255-5138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-15
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty