Basic Information
| Provider Information | |||||||||
| NPI: | 1356790158 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANNER UMC DPEC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 S COUNTRY CLUB ROAD | ||||||||
| Address2: | 130 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208742000 | ||||||||
| FaxNumber: | 5208744801 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 S COUNTRY CLUB ROAD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208742000 | ||||||||
| FaxNumber: | 5208744801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2016 | ||||||||
| LastUpdateDate: | 06/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | PENDERGRASS | ||||||||
| AuthorizedOfficialFirstName: | MERRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5206266376 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | 942958258 | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No ID Information.