MEDICARE: BANNER OCCUPATIONAL HEALTH ARIZONA 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	261QX0100X	Occupational Medicine Clinic/Center

General Provider Information

NPI Number	:	1811530611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANNER OCCUPATIONAL HEALTH ARIZONA LLC

Provider Business Mailing Address
First Line	:	2901 N CENTRAL AVE STE 160
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2702
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9305 W THOMAS RD STE 235
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85037-3363
Country	:	US
Telephone Number	:	623-327-4100
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	DENNIS LARAWAY
Credential	:
Telephone Number	:	602-747-4000

Provider Enumeration Date	:	10/24/2019
Last Update Date	:	10/24/2019

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