Healthcare Provider Details

I. General information

NPI: 1073802161
Provider Name (Legal Business Name): MARC BERNARD GLADDEN II D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 S UNIVERSITY AVE STE 200
BEAVER DAM WI
53916-3079
US

IV. Provider business mailing address

705 S UNIVERSITY AVE STE 200
BEAVER DAM WI
53916-3079
US

V. Phone/Fax

Practice location:
  • Phone: 920-887-9272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number62570-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number62570-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: