Provider Demographics
NPI:1114962321
Name:BANNER ESTRELLA SURGERY CENTER
Entity Type:Organization
Organization Name:BANNER ESTRELLA SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4000
Mailing Address - Street 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:602-747-4000
Mailing Address - Fax:
Practice Address - Street 1:9301 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3327
Practice Address - Country:US
Practice Address - Phone:623-388-5700
Practice Address - Fax:623-478-7499
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-19
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOSC5846261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
105102Medicare ID - Type Unspecified
AZ954330Medicaid
Z165645Medicare PIN