MEDICARE: BANNER ARIZONA ASC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	OSC3833	AZ

General Provider Information

NPI Number	:	1417921537
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANNER ARIZONA ASC LLC

Provider Business Mailing Address
First Line	:	14416 W MEEKER BLVD
Second Line	:	SUITE 103
City	:	SUN CITY WEST
State	:	AZ
Zip	:	85375-5284
Country	:	US
Telephone Number	:	623-583-5280
Fax Number	:	623-583-5277

Provider Business Practice Location Address
First Line	:	14416 W MEEKER BLVD
Second Line	:	SUITE 103
City	:	SUN CITY WEST
State	:	AZ
Zip	:	85375-5284
Country	:	US
Telephone Number	:	623-583-5280
Fax Number	:	623-583-5277

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PHILLIP A CLENDENIN
Credential	:
Telephone Number	:	615-665-1283

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	09/07/2023

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