Healthcare Provider Details

I. General information

NPI: 1114301017
Provider Name (Legal Business Name): BANNER HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 S PONDEROSA ST
PAYSON AZ
85541-5542
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 928-474-3222
  • Fax: 928-474-1295
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: DENNIS LARAWAY
Title or Position: CFO
Credential:
Phone: 602-747-4000