Provider Demographics
NPI:1689635914
Name:MADSEN, EDWARD K (PC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:K
Last Name:MADSEN
Suffix:
Gender:M
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 958
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-0958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:590 E 100 N
Practice Address - Street 2:STE 4
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501
Practice Address - Country:US
Practice Address - Phone:435-637-7551
Practice Address - Fax:435-636-0499
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2014-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1612038905305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization