Provider Demographics
NPI:1487852075
Name:JERRY MARSDEN MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JERRY MARSDEN MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-628-3334
Mailing Address - Street 1:1490 E FOREMASTER DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4488
Mailing Address - Country:US
Mailing Address - Phone:435-628-3334
Mailing Address - Fax:
Practice Address - Street 1:1490 E FOREMASTER DR
Practice Address - Street 2:SUITE 350
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4488
Practice Address - Country:US
Practice Address - Phone:435-628-3334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT153367-1205207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528562878007Medicaid
UTC 64048Medicare UPIN
UT000061217Medicare PIN