Provider Demographics
NPI:1487629150
Name:MCSPADDEN, GLEN F (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:F
Last Name:MCSPADDEN
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 1:13763 COLLINE RD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-9147
Mailing Address - Country:US
Mailing Address - Phone:479-426-9940
Mailing Address - Fax:
Practice Address - Street 1:1101 JACKSON ST SW
Practice Address - Street 2:
Practice Address - City:GRAVETTE
Practice Address - State:AR
Practice Address - Zip Code:72736-9121
Practice Address - Country:US
Practice Address - Phone:479-787-5291
Practice Address - Fax:479-344-6404
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24242207P00000X
ARE4542207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200052620AMedicaid
OK200052620AMedicaid
AR5N469Medicare PIN
OK2435415702Medicare PIN