Provider Demographics
NPI:1750665980
Name:BANNER URGENT CARE ARIZONA LLC
Entity Type:Organization
Organization Name:BANNER URGENT CARE 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:
Mailing Address - Fax:
Practice Address - Street 1:15468 N CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7469
Practice Address - Country:US
Practice Address - Phone:623-584-2917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-06
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ653587Medicaid
AZZ149905Medicare PIN