Provider Demographics
NPI:1669348157
Name:GOLD CANYON INTERNAL MEDICINE, PLLC
Entity type:Organization
Organization Name:GOLD CANYON INTERNAL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:K
Authorized Official - Last Name:FAHNBULLEH
Authorized Official - Suffix:
Authorized Official - Credentials:NA
Authorized Official - Phone:602-300-7301
Mailing Address - Street 1:5440 E SOUTHERN AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2779
Mailing Address - Country:US
Mailing Address - Phone:480-626-4999
Mailing Address - Fax:480-306-3239
Practice Address - Street 1:5440 E SOUTHERN AVE STE 105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2779
Practice Address - Country:US
Practice Address - Phone:480-626-4999
Practice Address - Fax:480-303-4323
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOLD CANYON INTERNAL MEDICINE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-10-13
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty