Healthcare Provider Details

I. General information

NPI: 1134172679
Provider Name (Legal Business Name): BANNER GOOD SAMARITAN BARIATRIC PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST
PHOENIX AZ
85006-2850
US

IV. Provider business mailing address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 602-239-5000
  • Fax: 602-239-3339
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DENNIS DAHLEN
Title or Position: SR VICE PRESIDENT - FINANCE
Credential:
Phone: 602-495-4000