Basic Information
| Provider Information | |||||||||
| NPI: | 1508941691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANNER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851050 | ||||||||
| FaxNumber: | 6828857572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 05/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | K2217 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 10011835 | 01 | TX | AMERIGROUP PIN | OTHER | 124029 | 01 | TX | SUPERIOR PIN | OTHER | 043860808 | 01 | TX | CSHCN | OTHER | 1727210 | 01 | TX | FIRSTHEALTH PIN | OTHER | 413461 | 01 | TX | PHCS PIN | OTHER | 043860807 | 05 | TX | MEDICAID | 00U87Z | 01 | TX | BCBSTX GRP PIN | OTHER | 85381B | 01 | TX | BCBSTX IND PIN | OTHER | 1750369203 | 01 | GRP NPI NUMBER | OTHER |