Provider Demographics
NPI:1447381207
Name:BANNER ARIZONA MEDICAL CLINIC LTD
Entity Type:Organization
Organization Name:BANNER ARIZONA MEDICAL CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-876-3967
Mailing Address - Street 1:13640 N PLAZA DEL RIO BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4846
Mailing Address - Country:US
Mailing Address - Phone:623-876-3800
Mailing Address - Fax:
Practice Address - Street 1:14418 W MEEKER BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5283
Practice Address - Country:US
Practice Address - Phone:623-876-3952
Practice Address - Fax:623-583-5243
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-07
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC3931332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ516437Medicaid
AZZWCFGWMedicare PIN
AZZWCKJDMedicare PIN
AZ516437Medicaid