Provider Demographics
NPI:1063525954
Name:CANYON PARK MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:CANYON PARK MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-348-6611
Mailing Address - Street 1:1501 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-6618
Mailing Address - Country:US
Mailing Address - Phone:405-348-6611
Mailing Address - Fax:405-348-9280
Practice Address - Street 1:1501 E 19TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-6618
Practice Address - Country:US
Practice Address - Phone:405-348-6611
Practice Address - Fax:405-348-9280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8699261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37DO469469OtherCLIA #
OKCH5055OtherRAILROAD MEDICARE #
OK100748060AMedicaid
OK4589400001OtherDMERC GROUP #
OK=========001OtherBCBS GROUP #
OK400522056Medicare ID - Type UnspecifiedMEDICARE GROUP #