Provider Demographics
NPI:1619567922
Name:BANNER UNIVERSITY MEDICAL GROUP ADULT SLEEP, LLC
Entity Type:Organization
Organization Name:BANNER UNIVERSITY MEDICAL GROUP ADULT SLEEP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
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 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 1:755 E MCDOWELL RD ANNEX BLDG
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2502
Practice Address - Country:US
Practice Address - Phone:602-521-3501
Practice Address - Fax:480-655-2565
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER UNIVERSITY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-20
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic