NPIMap

Organization Active NPI

Banner Physician Super Specialists Arizona LLC

  • Nutrition Education Nutritionist
  • Mesa, AZ
National Provider Identifier
1790337665
Registry record updated Dec 28, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nutrition Education NutritionistTaxonomy code 133NN1002X
Legal business name
BANNER PHYSICIAN SUPER SPECIALISTS ARIZONA LLC
Practice address
1450 S Dobson Rd Ste B221
Mesa, AZ 85202-4745
Phone
(480) 827-5370
NPI assigned
Jul 11, 2019
Last updated
Dec 28, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
BANNER HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 28, 2021

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Nutrition Education NutritionistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 133NN1002X Primary
Multi-Specialty Clinic/Center 261QM1300X

Addresses

Primary practice location

1450 S Dobson Rd Ste B221
Mesa, AZ 85202-4745

Mailing address

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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20111228000353 AZ Part B Supplier - Clinic/Group Practice 7911173794 Receives reassigned benefits from 207 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Buckeye, AZ; Sun City West, AZ; Scottsdale, AZ; San Tan Valley, AZ; Queen Creek, AZ; Phoenix, AZ; Mesa, AZ; Maricopa, AZ…

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Banner Physician Super Specialists Arizona LLC4 organizations share this tax ID, including this one
Part of
Custer Comm Hosp Rad

Other organizations with this tax ID 3

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

Locations

1432 S Dobson Rd
Ste 501
Mesa, AZ 85202
Phone (480) 412-7474

1432 S Dobson Rd
Ste 512
Mesa, AZ 85202
Phone (480) 412-6336

Practitioners & affiliated clinicians

Practitioners 33

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 33

NPI Registry JSON

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

{
    "created_epoch": "1562803200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1640649600000",
    "number": "1790337665",
    "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": "1450 S DOBSON RD STE B221",
            "city": "MESA",
            "state": "AZ",
            "postal_code": "852024745",
            "telephone_number": "480-827-5370"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BANNER PHYSICIAN SUPER SPECIALISTS ARIZONA LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "BANNER HEALTH",
        "enumeration_date": "2019-07-11",
        "last_updated": "2021-12-28",
        "certification_date": "2021-12-28",
        "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": "133NN1002X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Nutritionist, Nutrition, Education",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Mesa, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.