Provider Demographics
NPI:1639103062
Name:MADSEN, KURT ROBERT ERIK (DO)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:ROBERT ERIK
Last Name:MADSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E HOSPITAL LN
Mailing Address - Street 2:SUITE 205
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4230
Mailing Address - Country:US
Mailing Address - Phone:812-234-2663
Mailing Address - Fax:812-242-5878
Practice Address - Street 1:501 E HOSPITAL LN
Practice Address - Street 2:SUITE 205
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4230
Practice Address - Country:US
Practice Address - Phone:812-234-2663
Practice Address - Fax:812-242-5878
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001875207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000577747OtherBLUE CROSS/BLUE SHIELD
IN200217870Medicaid
IN000000490011OtherBLUE SHIELD
IN000000577747OtherBLUE CROSS/BLUE SHIELD
G65943Medicare UPIN
IN200217870Medicaid
P00348786Medicare PIN