Healthcare Provider Details

I. General information

NPI: 1013707207
Provider Name (Legal Business Name): BANNER FORT COLLINS PCP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3519 RICHMOND DR
FORT COLLINS CO
80526-5995
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 970-449-0951
  • Fax:
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
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHIVA BIRDI
Title or Position: CEO
Credential:
Phone: 602-747-4000