Provider Demographics
NPI:1811419708
Name:BLACK CANYON MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:BLACK CANYON MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGUFFEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-365-2735
Mailing Address - Street 1:426 HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-9461
Mailing Address - Country:US
Mailing Address - Phone:208-365-2735
Mailing Address - Fax:208-365-2737
Practice Address - Street 1:426 HIGHWAY 16
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9461
Practice Address - Country:US
Practice Address - Phone:208-365-2735
Practice Address - Fax:208-365-2737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1346654589Medicaid
ID1306873435Medicaid