Healthcare Provider Details

I. General information

NPI: 1639417660
Provider Name (Legal Business Name): BANNER HOSPITAL BASED PHYSICIANS COLORADO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2013
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 BOISE AVE STE B
LOVELAND CO
80538-5036
US

IV. Provider business mailing address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 970-679-8900
  • Fax: 970-679-8940
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 LARAWAY
Title or Position: CFO
Credential:
Phone: 602-747-4000