Provider Demographics
NPI:1386674240
Name:BANNER ARIZONA MEDICAL CLINIC, LTD
Entity Type:Organization
Organization Name:BANNER ARIZONA MEDICAL CLINIC, LTD
Other - Org Name:BANNER ARIZONA MEDICAL CLINIC, LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-876-3967
Mailing Address - Street 1:14418 W MEEKER BLVD
Mailing Address - Street 2:STE 105
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-5283
Mailing Address - Country:US
Mailing Address - Phone:623-583-5240
Mailing Address - Fax:623-583-5235
Practice Address - Street 1:14418 W MEEKER BLVD
Practice Address - Street 2:STE 105
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5283
Practice Address - Country:US
Practice Address - Phone:623-583-5240
Practice Address - Fax:623-583-5235
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-04
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7-548261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ959520Medicaid
AZP00216436Medicare PIN
AZ959520Medicaid