Basic Information
Provider Information | |||||||||
NPI: | 1487785002 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BANNER ARIZONA MEDICAL CLINIC LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13640 N PLAZA DEL RIO BLVD | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | AZ | ||||||||
PostalCode: | 853814846 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6238763800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13760 N 93RD AVE | ||||||||
Address2: |   | ||||||||
City: | PEORIA | ||||||||
State: | AZ | ||||||||
PostalCode: | 853814201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6238763952 | ||||||||
FaxNumber: | 6238763975 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2007 | ||||||||
LastUpdateDate: | 09/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURKE | ||||||||
AuthorizedOfficialFirstName: | MARGARET | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6238763967 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BANNER HEALTH | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | OTC3932 | AZ | N |   | Suppliers | Prosthetic/Orthotic Supplier |   | 332B00000X | OTC3932 | AZ | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 516437 | 05 | AZ |   | MEDICAID |