Provider Demographics
NPI:1528588621
Name:GLIDEWELL, RYAN JAMES (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:GLIDEWELL
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:PO BOX 10185
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-0185
Mailing Address - Country:US
Mailing Address - Phone:865-584-7376
Mailing Address - Fax:865-540-3856
Practice Address - Street 1:555 HARTSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-2400
Practice Address - Country:US
Practice Address - Phone:615-452-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10061530207R00000X
AZ659632085R0202X
TN673132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ081969Medicaid