Provider Demographics
NPI:1417312760
Name:BANNER - UNIVERSITY PHYSICIAN SPECIALISTS LLC
Entity Type:Organization
Organization Name:BANNER - UNIVERSITY PHYSICIAN SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LARAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4000
Mailing Address - Street 1:2901 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 N NAVAJO DR
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040
Practice Address - Country:US
Practice Address - Phone:928-645-0131
Practice Address - Fax:928-645-3549
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER -- UNIVERSITY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-30
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty