Provider Demographics
NPI:1043324312
Name:CANYONS MEDICAL CENTER PC
Entity type:Organization
Organization Name:CANYONS MEDICAL CENTER PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:COBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-666-6650
Mailing Address - Street 1:PO BOX 980700
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-0700
Mailing Address - Country:US
Mailing Address - Phone:801-572-1616
Mailing Address - Fax:801-572-3106
Practice Address - Street 1:9355 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3135
Practice Address - Country:US
Practice Address - Phone:801-572-1616
Practice Address - Fax:801-572-3106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2625861205261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========OtherBLUE CROSS
UTF79473Medicare UPIN
UT000057818Medicare PIN