Basic Information
| Provider Information | |||||||||
| NPI: | 1639842677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANNER -- UNIVERSITY MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 N CENTRAL AVE STE 160 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122702 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6261 N LA CHOLLA BLVD STE 131 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857413556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206945437 | ||||||||
| FaxNumber: | 5206943941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2021 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | LARAWAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 133NN1002X | Y | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education |
No ID Information.