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NPI Code Detail

MEDICARE: BANNER MEDICAL GROUP GREELEY LLC

MEDICARE: BANNER MEDICAL GROUP GREELEY LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM1300XMulti-Specialty Clinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1104070333
Entity Type Code : Organization
Provider Name (Legal Business Name) : BANNER MEDICAL GROUP GREELEY LLC
Provider Business Mailing Address
First Line : 1441 N 12TH ST
Second Line :
City : PHOENIX
State : AZ
Zip : 85006-2837
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 5623 W 19TH ST
Second Line :
City : GREELEY
State : CO
Zip : 80634-2901
Country : US
Telephone Number : 970-353-9011
Fax Number :
Authorized Official
Title or Position : SR VP FINANCE
Name : DENNIS DAHLEN
Credential :
Telephone Number : 602-747-4000
Provider Enumeration Date : 11/14/2008
Last Update Date : 09/20/2010

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Directions to “BANNER MEDICAL GROUP GREELEY LLC ” Practice Location

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