MEDICARE: CANYON GATE MEDICAL GROUP, LLC

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	207R00000X	Internal Medicine Physician	12804	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396994943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANYON GATE MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	2929 N UNIVERSITY DR
Second Line	:	SUITE 110
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33065-5081
Country	:	US
Telephone Number	:	954-656-8855
Fax Number	:

Provider Business Practice Location Address
First Line	:	9280 W SUNSET RD
Second Line	:	SUITE 426
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-4860
Country	:	US
Telephone Number	:	702-262-0124
Fax Number	:	702-262-0143

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICKI MOSKOW
Credential	:
Telephone Number	:	954-656-8855

Provider Enumeration Date	:	09/18/2008
Last Update Date	:	04/20/2009

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Directions to “CANYON GATE MEDICAL GROUP, LLC ” Practice Location

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