Healthcare Provider Details

I. General information

NPI: 1124071162
Provider Name (Legal Business Name): BANNER -- UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST #610
PHOENIX AZ
85006-2848
US

IV. Provider business mailing address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 602-239-4161
  • Fax: 602-239-4233
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DENNIS E DAHLEN
Title or Position: SR VICE PRESIDENT - FINANCE
Credential:
Phone: 602-747-4000