Provider Demographics
NPI:1972799856
Name:BLACK CANYON MEDICAL
Entity Type:Organization
Organization Name:BLACK CANYON MEDICAL
Other - Org Name:BRADSHAW MOUNTAIN FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:623-742-6428
Mailing Address - Street 1:46641 N BLACK CANYON HWY
Mailing Address - Street 2:STE 5
Mailing Address - City:NEW RIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85087-6941
Mailing Address - Country:US
Mailing Address - Phone:623-742-6428
Mailing Address - Fax:623-465-1561
Practice Address - Street 1:17301 E SPRING VALLEY RD
Practice Address - Street 2:STE F
Practice Address - City:SPRING VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86333-4263
Practice Address - Country:US
Practice Address - Phone:928-632-4909
Practice Address - Fax:623-374-5576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3297207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty