Provider Demographics
NPI:1508253717
Name:BINNEBOESE, ADAM (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:BINNEBOESE
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 1:978 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1545
Mailing Address - Country:US
Mailing Address - Phone:605-659-4075
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E RM 1A71
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132
Practice Address - Country:US
Practice Address - Phone:605-659-4075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-26
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10077796-12052085R0202X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice