Provider Demographics
NPI:1972500049
Name:GLIDEWELL, TODD J (DC)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:J
Last Name:GLIDEWELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 CAROL DR
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1922
Mailing Address - Country:US
Mailing Address - Phone:570-587-3175
Mailing Address - Fax:
Practice Address - Street 1:927 MAIN ST
Practice Address - Street 2:
Practice Address - City:DICKSON CITY
Practice Address - State:PA
Practice Address - Zip Code:18519-1337
Practice Address - Country:US
Practice Address - Phone:570-383-2222
Practice Address - Fax:570-383-3851
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007226-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01686826Medicaid
PAU75244Medicare UPIN
PA01686826Medicaid