Healthcare Provider Details

I. General information

NPI: 1073295036
Provider Name (Legal Business Name): BANNER PHYSICIAN SPECIALISTS ARIZONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 W ASPERA BLVD STE 101 201 301
GLENDALE AZ
85308-7935
US

IV. Provider business mailing address

2901 N CENTRAL AVE STE 160
PHOENIX AZ
85012-2702
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SHIVA BIRDI
Title or Position: VP BMG
Credential:
Phone: 602-747-4000