Provider Demographics
NPI:1174635494
Name:BLACKHAM, BRENDA K (MD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:K
Last Name:BLACKHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2975 EXECUTIVE PKWY
Mailing Address - Street 2:200
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-9642
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:801-990-1912
Practice Address - Street 1:5770 FASHION BLVD
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6548
Practice Address - Country:US
Practice Address - Phone:801-993-9582
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT90183338-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1189492500Medicaid
UT6761OtherHEALTHY U
UT870545614BL3OtherEDUCATORS MUTUAL
UT1502954OtherUMWA
UT73606OtherPEHP
UT107005709102OtherIHC
AZ824723Medicaid
UTQM0000075886OtherALTIUS
UT2090168OtherUNITED HEALTHCARE
UTPRA06458OtherMOLINA
UT305404OtherDESERET MUTUAL
UT107005709102OtherIHC
UTQM0000075886OtherALTIUS