Provider Demographics
NPI:1164412862
Name:MADSEN, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MADSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 NORTHDALE BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1075 N CURTIS RD STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1348
Practice Address - Country:US
Practice Address - Phone:208-302-2800
Practice Address - Fax:208-302-2825
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6720A208600000X, 2086S0129X
NC2018-01195208600000X
IDM-123722086S0129X
FLME1537222086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01371657Medicaid
WY121692900Medicaid
WY121692900Medicaid
CO381372ZNHBMedicare PIN