MEDICARE: CANYON PEDIATRICS, INC

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	207Q00000X	Family Medicine Physician
2	208000000X	Pediatrics Physician
3	261Q00000X	Clinic/Center
4	302R00000X	Health Maintenance Organization	20136	AZ
5	261QP2300X	Primary Care Clinic/Center

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
2	AZ0889880	OTHER	AZ	BLUE CROSS BLUE SHEILD
3	2048349	OTHER	AZ	AETNA HEALTH CAER
4	183427266	OTHER	AZ	TRICARE
5	6327185	OTHER	AZ	CIGNA US HEALTH CARE
6	1Z5874	OTHER	AZ	HEALTH NET

General Provider Information

NPI Number	:	1831185362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANYON PEDIATRICS, INC

Provider Business Mailing Address
First Line	:	2451 E BASELINE RD
Second Line	:	STE 130
City	:	GILBERT
State	:	AZ
Zip	:	85234-2471
Country	:	US
Telephone Number	:	480-507-2213
Fax Number	:	480-626-6508

Provider Business Practice Location Address
First Line	:	2451 E BASELINE RD
Second Line	:	SUITE 200
City	:	GILBERT
State	:	AZ
Zip	:	85234-2471
Country	:	US
Telephone Number	:	480-507-2213
Fax Number	:	480-626-6508

Authorized Official
Title or Position	:	CEO
Name	:	RICHARD BRUBAKER
Credential	:	LMSW
Telephone Number	:	480-776-7155

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	03/28/2024

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Directions to “CANYON PEDIATRICS, INC ” Practice Location

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