Provider Demographics
NPI:1124073747
Name:BANNER -- UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS FAMILY MEDICINE
Entity type:Organization
Organization Name:BANNER -- UNIVERSITY MEDICAL CENTER PHOENIX CAMPUS FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT - FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4000
Mailing Address - Street 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:STE 605
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-239-4567
Practice Address - Fax:602-239-2067
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-23
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ767618Medicaid
AZZ74065Medicare PIN