Provider Demographics
NPI:1053176677
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:480-507-2199
Mailing Address - Street 1:2451 E BASELINE RD STE 130
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2487
Mailing Address - Country:US
Mailing Address - Phone:480-776-7155
Mailing Address - Fax:
Practice Address - Street 1:2451 E BASELINE RD STE 200
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2405
Practice Address - Country:US
Practice Address - Phone:480-776-7155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-14
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ053504Medicaid