Basic Information
| Provider Information | |||||||||
| NPI: | 1225169188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANNER ARIZONA MEDICAL CLINIC LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13640 N PLAZA DEL RIO BLVD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238763800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14420 W MEEKER BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853755286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238765300 | ||||||||
| FaxNumber: | 6235835301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 09/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6238763967 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | OTC3947 | AZ | N | Suppliers | Prosthetic/Orthotic Supplier | 332B00000X | OTC3947 | AZ | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 516437 | 05 | AZ | MEDICAID |