Healthcare Provider Details

I. General information

NPI: 1326710906
Provider Name (Legal Business Name): BANNER PHYSICIAN SPECIALISTS ARIZONA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9165 W THUNDERBIRD RD
PEORIA AZ
85381-4847
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 623-285-1120
  • Fax: 623-285-2626
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name: DENNIS LARAWAY
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 602-747-4000