MEDICARE: CANYON STATE ANESTHESIOLOGISTS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1265439525
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANYON STATE ANESTHESIOLOGISTS PC

Provider Business Mailing Address
First Line	:	8102 E MCDOWELL RD
Second Line	:	SUITE 2A
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85257-3809
Country	:	US
Telephone Number	:	480-421-1014
Fax Number	:	480-421-9697

Provider Business Practice Location Address
First Line	:	8102 E MCDOWELL RD
Second Line	:	SUITE 2A
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85257-3809
Country	:	US
Telephone Number	:	480-421-1014
Fax Number	:	480-421-9697

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MOREEN KOPPULA
Credential	:	M.D.
Telephone Number	:	480-421-1014

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	01/28/2008

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