=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730061094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BANNER PRIMARY CARE PHYSICIANS ARIZONA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2025
-----------------------------------------------------
Last Update Date | 07/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20751 W MARKET ST
-----------------------------------------------------
City | BUCKEYE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85396-7893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-463-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2901 N CENTRAL AVE STE 160
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-747-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SHIVA BIRDI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-747-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------