NPIMap

Organization Active NPI

Banner Health

Doing business as Good Samaritan Medicine Residency 12th St

  • Non-Pharmacy Dispensing Site
  • Phoenix, AZ
National Provider Identifier
1316358013
Registry record updated Jan 31, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Non-Pharmacy Dispensing SiteTaxonomy code 332900000X
License
45424 Issued in AZ
Legal business name
BANNER HEALTH
Doing business as
Good Samaritan Medicine Residency 12th St
Practice address
1300 N 12TH St
Suite 605
Phoenix, AZ 85006-2848
Phone
(602) 839-2668
NPI assigned
May 15, 2014
Last updated
Jan 31, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
MEDVANTX, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 31, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dennis Laraway
Title
Cfo
Phone
(602) 747-4000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Non-Pharmacy Dispensing Site 332900000X 45424 AZ Primary

Addresses

Primary practice location

1300 N 12TH St
Suite 605
Phoenix, AZ 85006-2848

Mailing address

2901 N Central Ave Ste 160
Phoenix, AZ 85012-2702

Other names 1

  • Good Samaritan Medicine Residency 12th St Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Big Horn Family Med28 organizations share this tax ID, including this one
Part of
Medvantx Inc

Other organizations with this tax ID 27

Organizations that report the same tax identification number in the National Provider Directory.

View all 27

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1400112000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1643587200000",
    "number": "1316358013",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2901 N CENTRAL AVE STE 160",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850122702"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1300 N 12TH ST",
            "address_2": "SUITE 605",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850062848",
            "telephone_number": "602-839-2668"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BANNER HEALTH",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MEDVANTX, INC.",
        "enumeration_date": "2014-05-15",
        "last_updated": "2022-01-31",
        "certification_date": "2022-01-31",
        "status": "A",
        "authorized_official_last_name": "LARAWAY",
        "authorized_official_first_name": "DENNIS",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "602-747-4000"
    },
    "taxonomies": [
        {
            "code": "332900000X",
            "taxonomy_group": "",
            "desc": "Non-Pharmacy Dispensing Site",
            "state": "AZ",
            "license": "45424",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Good Samaritan Medicine Residency 12th St",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Good Samaritan Medicine Residency 12th St",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Phoenix, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 31, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.