Healthcare Provider Details

I. General information

NPI: 1174635494
Provider Name (Legal Business Name): BRENDA K BLACKHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 FASHION BLVD
MURRAY UT
84107-6548
US

IV. Provider business mailing address

2975 EXECUTIVE PKWY 200
LEHI UT
84043-9642
US

V. Phone/Fax

Practice location:
  • Phone: 801-993-9582
  • Fax: 801-733-5618
Mailing address:
  • Phone: 801-990-1911
  • Fax: 801-990-1912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number90183338-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: