Healthcare Provider Details

I. General information

NPI: 1689289084
Provider Name (Legal Business Name): BANNER HEALTH PHYSICIANS COLORADO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 09/11/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 14TH ST
WHEATLAND WY
82201-3201
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 307-322-3636
  • 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

VIII. Authorized Official

Name: DENNIS E DAHLEN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 602-747-4000