Basic Information
| Provider Information | |||||||||
| NPI: | 1639191612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'BANNON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 NEWNAN STATION DR | ||||||||
| Address2: | STE A | ||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302653194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708146011 | ||||||||
| FaxNumber: | 7708146011 | ||||||||
| Practice Location | |||||||||
| Address1: | 13040 ABERCORN ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314191955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706459181 | ||||||||
| FaxNumber: | 7706458455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 22326 | WV | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 060309 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 433679505B | 05 | GA | MEDICAID |