Basic Information
| Provider Information | |||||||||
| NPI: | 1770762635 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANNER CARDIO-THORACIC AND VASCULAR SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 N 12TH ST | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062837 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6750 E BAYWOOD AVE | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852061749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804612409 | ||||||||
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| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 10/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | DAHLEN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VICE PRESIDENT FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.