Provider Demographics
NPI: | 1184852386 |
---|---|
Name: | BANNER GREELEY SPECIALISTS |
Entity Type: | Organization |
Organization Name: | BANNER GREELEY SPECIALISTS |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | SR VP 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: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1801 16TH ST |
Practice Address - Street 2: | |
Practice Address - City: | GREELEY |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80631-5154 |
Practice Address - Country: | US |
Practice Address - Phone: | 970-378-4529 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | BANNER HEALTH |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2009-06-25 |
Last Update Date: | 2009-08-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CO | 38955067 | Medicaid | |
COB4676 | Medicare PIN |