Provider Demographics
NPI:1922820935
Name:BANNER-UNIVERSITY MEDICAL GROUP
Entity type:Organization
Organization Name:BANNER-UNIVERSITY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:602-747-4000
Mailing Address - Fax:
Practice Address - Street 1:707 N ALVERNON WAY STE 301
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1848
Practice Address - Country:US
Practice Address - Phone:520-694-1460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-30
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies