Healthcare Provider Details

I. General information

NPI: 1801134812
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: 01/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 14TH ST
WHEATLAND WY
82201-3201
US

IV. Provider business mailing address

1441 N 12TH ST
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 970-392-2135
  • Fax: 970-378-3825
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 DAHLEN
Title or Position: SR VP FINANCE
Credential:
Phone: 602-474-4000