Basic Information
| Provider Information | |||||||||
| NPI: | 1992018113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BANNER MEDICAL GROUP GREELEY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1441 N 12TH ST | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027474000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 70TH AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806344621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703784155 | ||||||||
| FaxNumber: | 9703784151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2010 | ||||||||
| LastUpdateDate: | 07/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | DAHLEN | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6027474000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BANNER HEALTH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.