Provider Demographics
NPI:1164150363
Name:BANNER PHYSICIAN SPECIALISTS ARIZONA LLC
Entity Type:Organization
Organization Name:BANNER PHYSICIAN SPECIALISTS ARIZONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/BMG
Authorized Official - Prefix:
Authorized Official - First Name:SHIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4000
Mailing Address - Street 1:2901 N CENTRAL AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7701 W ASPERA BLVD STES 102, 201, 301
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7935
Practice Address - Country:US
Practice Address - Phone:623-248-2100
Practice Address - Fax:623-707-4809
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty