Healthcare Provider Details

I. General information

NPI: 1588098313
Provider Name (Legal Business Name): BANNER HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST SUITE 520
PHOENIX AZ
85006-2848
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 602-839-4456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number19036
License Number StateAZ

VIII. Authorized Official

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