Basic Information
| Provider Information | |||||||||
| NPI: | 1275725772 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANJOH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ADERONKE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MBA, RT(R) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1670 CLAIRMONT RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1670 CLAIRMONT RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2007 | ||||||||
| LastUpdateDate: | 08/17/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2471C3402X | 407722 | GA | Y | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Radiography |
No ID Information.