Provider Demographics
NPI:1740650555
Name:BANNER - UNIVERSITY SUPER SPECIALISTS LLC
Entity type:Organization
Organization Name:BANNER - UNIVERSITY SUPER SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VENKATA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANI
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 1:2901 N CENTRAL AVE STE 160
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2702
Practice Address - Country:US
Practice Address - Phone:602-747-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER UNIVERSITY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-06
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
No282N00000XHospitalsGeneral Acute Care Hospital