Provider Demographics
NPI:1396766432
Name:HADDEN, H. ROSS (DPM)
Entity type:Individual
Prefix:DR
First Name:H.
Middle Name:ROSS
Last Name:HADDEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 MCGRAW DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6012
Mailing Address - Country:US
Mailing Address - Phone:309-663-2306
Mailing Address - Fax:309-662-1213
Practice Address - Street 1:2708 MCGRAW DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6012
Practice Address - Country:US
Practice Address - Phone:309-663-2306
Practice Address - Fax:309-662-1213
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016002451213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016002451Medicaid
IL016002451Medicaid
ILP15830Medicare PIN