Basic Information
| Provider Information | |||||||||
| NPI: | 1811048275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANZ | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | MS, PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 UNIVERSITY DR STE A6 | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010022385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4133665703 | ||||||||
| FaxNumber: | 4139922019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 17371 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Y68515 | 01 | MA | BCBSMA | OTHER | 0705080 | 05 | MA | MEDICAID | 11516494 | 01 | MA | AETNA | OTHER |