Provider Demographics
NPI:1679842223
Name:BANNER PHYSICIAN SPECIALISTS ARIZONA LLC
Entity Type:Organization
Organization Name:BANNER PHYSICIAN SPECIALISTS ARIZONA 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:602-747-4000
Mailing Address - Fax:
Practice Address - Street 1:14420 W MEEKER BLVD
Practice Address - Street 2:STE 104
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5286
Practice Address - Country:US
Practice Address - Phone:623-583-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-27
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies