Provider Demographics
NPI:1265677678
Name:EDWARD K. MADSEN, M.D., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:EDWARD K. MADSEN, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:MADSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-637-7551
Mailing Address - Street 1:590 E 100 N STE 4
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-2600
Mailing Address - Country:US
Mailing Address - Phone:435-637-7551
Mailing Address - Fax:
Practice Address - Street 1:590 E 100 N STE 4
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-2600
Practice Address - Country:US
Practice Address - Phone:435-637-7551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-14
Last Update Date:2008-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1612038905305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization