=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982700720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANYON ORTHOPAEDIC SURGEONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2006
-----------------------------------------------------
Last Update Date | 08/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10450 W MCDOWELL RD STE 102
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-846-7614
-----------------------------------------------------
Fax | 623-848-4738
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10450 W MCDOWELL RD SUITE 102
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85392-4802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-846-7614
-----------------------------------------------------
Fax | 623-846-0993
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT PRACTICE MANAGER
-----------------------------------------------------
Name | MRS. JOANNA L POINDEXTER III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-846-7614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207XS0106X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Hand Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------