Provider Demographics
NPI:1417112541
Name:GOLD CANYON INTERNAL MEDICINE
Entity Type:Organization
Organization Name:GOLD CANYON INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-370-2602
Mailing Address - Street 1:9436 E THUNDER PASS DR
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-2064
Mailing Address - Country:US
Mailing Address - Phone:480-370-2602
Mailing Address - Fax:480-304-3239
Practice Address - Street 1:6724 S KINGS RANCH RD STE 102
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-2963
Practice Address - Country:US
Practice Address - Phone:480-626-4999
Practice Address - Fax:480-304-3239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25933207R00000X
AZ332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ404723Medicaid
AZ110180591Medicare PIN
AZF23967Medicare UPIN
AZZ21888Medicare PIN
AZ404723Medicaid