MEDICARE: BANNER GOOD SAMARITAN BARIATRIC PROGRAM

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
1	261Q00000X	Clinic/Center

Other Identifiers

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

General Provider Information

NPI Number	:	1134172679
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANNER GOOD SAMARITAN BARIATRIC PROGRAM

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	:	1300 N 12TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85006-2850
Country	:	US
Telephone Number	:	602-239-5000
Fax Number	:	602-239-3339

Authorized Official
Title or Position	:	SR VICE PRESIDENT - FINANCE
Name	:	DENNIS DAHLEN
Credential	:
Telephone Number	:	602-495-4000

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	10/15/2007

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