Provider Demographics
NPI:1205501392
Name:MADSEN, MICHAEL ROBERT (CPSS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:MADSEN
Suffix:
Gender:M
Credentials:CPSS
Other - Prefix:
Other - First Name:OBADIAH
Other - Middle Name:
Other - Last Name:MADSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6239 E BROWN RD STE 105
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4933
Mailing Address - Country:US
Mailing Address - Phone:480-477-9199
Mailing Address - Fax:602-610-1556
Practice Address - Street 1:6239 E BROWN RD STE 105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4933
Practice Address - Country:US
Practice Address - Phone:480-477-9199
Practice Address - Fax:602-610-1556
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1609334812Medicaid