Healthcare Provider Details

I. General information

NPI: 1891523338
Provider Name (Legal Business Name): BANNER HOSPITAL BASED PHYSICIANS COLORADO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 15TH ST STE 130
GREELEY CO
80631-4595
US

IV. Provider business mailing address

1800 15TH ST STE 130
GREELEY CO
80631-4595
US

V. Phone/Fax

Practice location:
  • Phone: 602-747-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

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