MEDICARE: BANNER HEALTH PHYSICIANS COLORADO 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
1	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1518559863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANNER HEALTH PHYSICIANS COLORADO LLC

Provider Business Mailing Address
First Line	:	2901 N CENTRAL AVE STE 160
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2702
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4650 SIGNAL TREE DR UNIT B200
Second Line	:
City	:	TIMNATH
State	:	CO
Zip	:	80547-4911
Country	:	US
Telephone Number	:	970-821-3830
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	DENNIS LARAWAY
Credential	:
Telephone Number	:	602-747-4000

Provider Enumeration Date	:	02/08/2021
Last Update Date	:	02/08/2021

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