Healthcare Provider Details

I. General information

NPI: 1356822902
Provider Name (Legal Business Name): GRAND CANYON ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9787 N 91ST ST STE 103
SCOTTSDALE AZ
85258-5088
US

IV. Provider business mailing address

PO BOX 737732
DALLAS TX
75373-7732
US

V. Phone/Fax

Practice location:
  • Phone: 480-657-0889
  • Fax:
Mailing address:
  • Phone: 888-717-5383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JEFF PERRY
Title or Position: VP OF RCM
Credential:
Phone: 502-418-4700