Healthcare Provider Details

I. General information

NPI: 1881913200
Provider Name (Legal Business Name): BANNER GOOD SAMARITAN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E MCDOWELL RD
PHOENIX AZ
85006-2612
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 602-836-4556
  • Fax:
Mailing address:
  • Phone: 602-836-4556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number261QM1300X
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number StateNULL

VIII. Authorized Official

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