Healthcare Provider Details

I. General information

NPI: 1831185362
Provider Name (Legal Business Name): CANYON PEDIATRICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 E BASELINE RD SUITE 200
GILBERT AZ
85234-2471
US

IV. Provider business mailing address

2451 E BASELINE RD STE 130
GILBERT AZ
85234-2471
US

V. Phone/Fax

Practice location:
  • Phone: 480-507-2213
  • Fax: 480-626-6508
Mailing address:
  • Phone: 480-507-2213
  • Fax: 480-626-6508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number20136
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RICHARD BRUBAKER
Title or Position: CEO
Credential: LMSW
Phone: 480-776-7155