Healthcare Provider Details

I. General information

NPI: 1750821310
Provider Name (Legal Business Name): WILLIAM GLENN HARDEMAN JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 BROADRICK DR
DALTON GA
30720-3011
US

IV. Provider business mailing address

1504 BROADRICK DR
DALTON GA
30720-3011
US

V. Phone/Fax

Practice location:
  • Phone: 706-278-6403
  • Fax: 706-278-0087
Mailing address:
  • Phone: 706-278-6403
  • Fax: 706-278-0087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number92013
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: