Provider Demographics
NPI:1174654891
Name:BLACK CANYON SURGEONS PC
Entity Type:Organization
Organization Name:BLACK CANYON SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SAWYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-240-0378
Mailing Address - Street 1:630 E STAR CT
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-6702
Mailing Address - Country:US
Mailing Address - Phone:970-240-0378
Mailing Address - Fax:970-240-3072
Practice Address - Street 1:630 E STAR CT
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-6702
Practice Address - Country:US
Practice Address - Phone:970-240-0378
Practice Address - Fax:970-240-3072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38476208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO807610OtherMEDICARE ID
COH21571Medicare UPIN