Provider Demographics
NPI:1558606020
Name:BANNER CHILDRENS BANNER HEALTH CLINIC LLC
Entity Type:Organization
Organization Name:BANNER CHILDRENS BANNER HEALTH CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BMG CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-256-3336
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 1:1760 E FLORENCE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-4765
Practice Address - Country:US
Practice Address - Phone:520-421-7400
Practice Address - Fax:520-421-7428
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-10
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty