Basic Information
| Provider Information | |||||||||
| NPI: | 1356978290 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANNON | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1759 CREEK VIEW DR | ||||||||
| Address2: | |||||||||
| City: | FOGELSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180511716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4847882338 | ||||||||
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| Practice Location | |||||||||
| Address1: | 225 E CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122274000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2020 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 125.075914 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.