Healthcare Provider Details

I. General information

NPI: 1821846726
Provider Name (Legal Business Name): BANNER PHYSICIAN SPECIALISTS ARIZONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 W EUGIE AVE STE 100
GLENDALE AZ
85304-1256
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 602-747-4000
  • Fax:
Mailing address:
  • Phone: 602-747-4000
  • 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: CEO/BMG
Credential:
Phone: 602-747-4000