Healthcare Provider Details

I. General information

NPI: 1124365531
Provider Name (Legal Business Name): CANYON UROLOGY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 W THUNDERBIRD RD STE B200
GLENDALE AZ
85306-4664
US

IV. Provider business mailing address

5750 W THUNDERBIRD RD STE B200
GLENDALE AZ
85306-4664
US

V. Phone/Fax

Practice location:
  • Phone: 602-375-1700
  • Fax: 602-978-1225
Mailing address:
  • Phone: 602-375-1700
  • Fax: 602-978-1225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KEN-RYU HAN
Title or Position: MANAGER
Credential: MD
Phone: 602-375-1700