Provider Demographics
NPI:1649414244
Name:CANYON GATE MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:CANYON GATE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSKOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-656-8855
Mailing Address - Street 1:2929 N UNIVERSITY DR
Mailing Address - Street 2:SUITE # 110
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5081
Mailing Address - Country:US
Mailing Address - Phone:954-656-8855
Mailing Address - Fax:954-656-8856
Practice Address - Street 1:3960 W. CRAIG ROAD
Practice Address - Street 2:SUITE # 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031
Practice Address - Country:US
Practice Address - Phone:702-473-8380
Practice Address - Fax:702-473-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBE527Medicare PIN