Basic Information
| Provider Information | |||||||||
| NPI: | 1750347936 | ||||||||
| 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 | ||||||||
| FaxNumber: | 6239729590 | ||||||||
| Practice Location | |||||||||
| Address1: | 13640 N PLAZA DEL RIO BLVD | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238763800 | ||||||||
| FaxNumber: | 6239729590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 12/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | DAHLEN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT - FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | OTC3936 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 0516437 | 05 | AZ | MEDICAID |