Healthcare Provider Details

I. General information

NPI: 1487629150
Provider Name (Legal Business Name): GLEN F MCSPADDEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 JACKSON ST SW
GRAVETTE AR
72736-9121
US

IV. Provider business mailing address

13763 COLLINE RD
BENTONVILLE AR
72712-9147
US

V. Phone/Fax

Practice location:
  • Phone: 479-787-5291
  • Fax: 479-344-6404
Mailing address:
  • Phone: 479-426-9940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number24242
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE4542
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE4542
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: