Healthcare Provider Details

I. General information

NPI: 1275528275
Provider Name (Legal Business Name): MERRILL LEE GLADDEN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 RIDGEWOOD DR STE A
BOWLING GREEN OH
43402-2694
US

IV. Provider business mailing address

1215 RIDGEWOOD DR STE A
BOWLING GREEN OH
43402-2694
US

V. Phone/Fax

Practice location:
  • Phone: 419-352-1519
  • Fax: 419-352-7004
Mailing address:
  • Phone: 419-352-1519
  • Fax: 419-352-7004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number35085092
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number35085092
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number35085092
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: