Healthcare Provider Details

I. General information

NPI: 1164412862
Provider Name (Legal Business Name): KENNETH MADSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 N CURTIS RD STE 101
BOISE ID
83706-1348
US

IV. Provider business mailing address

3810 NORTHDALE BLVD STE 150
TAMPA FL
33624-1871
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-2800
  • Fax: 208-302-2825
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number6720A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2018-01195
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number6720A
License Number StateWY
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberM-12372
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME153722
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: