Organization
CANYON PEDIATRICS, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RICHARD BRUBAKER LMSW (CEO)
(480) 776-7155
Entity
Organization
Contact information
Practice address
2451 E BASELINE RD, SUITE 200, GILBERT, AZ 85234-2471
(480) 507-2213
(480) 626-6508
Mailing address
2451 E BASELINE RD, STE 130, GILBERT, AZ 85234-2471
(480) 507-2213
(480) 626-6508
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
208000000X
Pediatrics Physician
—
—
261Q00000X
Clinic/Center
—
—
261QP2300X
Primary Care Clinic/Center
Primary
—
—
302R00000X
Health Maintenance Organization
20136
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
053504
—
AZ
01
—
183427266
TRICARE
AZ
01
—
1Z5874
HEALTH NET
AZ
01
—
2048349
AETNA HEALTH CAER
AZ
01
—
6327185
CIGNA US HEALTH CARE
AZ
01
—
AZ0889880
BLUE CROSS BLUE SHEILD
AZ
Enumeration date
09/20/2005
Last updated
03/28/2024
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