Healthcare Provider Details

I. General information

NPI: 1962803908
Provider Name (Legal Business Name): BANNER HEALTH PHYSICIANS ALASKA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 NOBLE ST
FAIRBANKS AK
99701-4948
US

IV. Provider business mailing address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 907-459-3507
  • Fax: 907-459-3532
Mailing address:
  • Phone: 602-747-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DENNIS DAHLEN
Title or Position: SR VP FINANCE
Credential:
Phone: 602-747-4000