Provider Demographics
NPI:1275787996
Name:MADSEN, MICHAEL BRENT (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRENT
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 1:1405 WEST 2200 SOUTSH
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119
Mailing Address - Country:US
Mailing Address - Phone:801-973-0900
Mailing Address - Fax:
Practice Address - Street 1:1405 W 2200 S
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1485
Practice Address - Country:US
Practice Address - Phone:801-973-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT159391-1265,8905207VH0002X
UT159391-1205, 8905207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD07843Medicare UPIN