Basic Information
| Provider Information | |||||||||
| NPI: | 1265439525 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANYON STATE ANESTHESIOLOGISTS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8102 E MCDOWELL RD | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852573809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804211014 | ||||||||
| FaxNumber: | 4804219697 | ||||||||
| Practice Location | |||||||||
| Address1: | 8102 E MCDOWELL RD | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852573809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804211014 | ||||||||
| FaxNumber: | 4804219697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | KOPPULA | ||||||||
| AuthorizedOfficialFirstName: | MOREEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4804211014 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.