Basic Information
Provider Information | |||||||||
NPI: | 1396994943 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CANYON GATE MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2929 N UNIVERSITY DR | ||||||||
Address2: | SUITE 110 | ||||||||
City: | CORAL SPRINGS | ||||||||
State: | FL | ||||||||
PostalCode: | 330655081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9546568855 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9280 W SUNSET RD | ||||||||
Address2: | SUITE 426 | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891484860 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7022620124 | ||||||||
FaxNumber: | 7022620143 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/18/2008 | ||||||||
LastUpdateDate: | 04/20/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOSKOW | ||||||||
AuthorizedOfficialFirstName: | RICKI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9546568855 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 12804 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1396994943 | 05 | NV |   | MEDICAID |