Individual
BANTI MAHANTA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1 SAINT ANTHONYS WAY, ALTON, IL 62002-4568
(618) 465-4520
Mailing address
PO BOX 500730, SAINT LOUIS, MO 63150-0730
(303) 465-0401
(303) 404-2317
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
036056611
IL
2085R0202X
Diagnostic Radiology Physician
35978
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036056611-1
—
IL
05
—
203599915
—
MO
01
—
300029507
RAILROAD MEDICARE
IL
Enumeration date
03/27/2006
Last updated
09/02/2008
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