Provider Demographics
NPI:1831185362
Name:CANYON PEDIATRICS, INC
Entity type:Organization
Organization Name:CANYON PEDIATRICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:480-776-7155
Mailing Address - Street 1:2451 E BASELINE RD
Mailing Address - Street 2:STE 130
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2471
Mailing Address - Country:US
Mailing Address - Phone:480-507-2213
Mailing Address - Fax:480-626-6508
Practice Address - Street 1:2451 E BASELINE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2471
Practice Address - Country:US
Practice Address - Phone:480-507-2213
Practice Address - Fax:480-626-6508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 208000000X, 261Q00000X, 261QP2300X
AZ20136302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ053504Medicaid
AZAZ0889880OtherBLUE CROSS BLUE SHEILD
AZ2048349OtherAETNA HEALTH CAER
AZ183427266OtherTRICARE
AZ6327185OtherCIGNA US HEALTH CARE
AZ1Z5874OtherHEALTH NET
AZ2048349OtherAETNA HEALTH CAER