Provider Demographics
NPI:1578746160
Name:COREY D ANDEN MD PC
Entity Type:Organization
Organization Name:COREY D ANDEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ANDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-387-2090
Mailing Address - Street 1:PO BOX 27688
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0688
Mailing Address - Country:US
Mailing Address - Phone:801-534-1360
Mailing Address - Fax:801-366-9883
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:#1875
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-2090
Practice Address - Fax:801-387-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057596Medicare PIN