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 1:974 E OLYMPUS PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-1545
Mailing Address - Country:US
Mailing Address - Phone:801-796-2264
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:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10077796-1205208D00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice