Provider Demographics
NPI:1386614568
Name:GLADE, BILLIE K (MD)
Entity type:Individual
Prefix:
First Name:BILLIE
Middle Name:K
Last Name:GLADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2537
Mailing Address - Country:US
Mailing Address - Phone:320-762-0399
Mailing Address - Fax:320-762-6847
Practice Address - Street 1:1527 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2537
Practice Address - Country:US
Practice Address - Phone:320-762-0399
Practice Address - Fax:320-762-6847
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN026121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1000272OtherPREFERRED ONE
MN31T07GLOtherBLUE SHIELD
MN763164OtherAMERICA'S PPO
MNA008OtherCHAMPUS
MNHP27497OtherHEALTH PARTNERS
MN1700778OtherMEDICA
MN1000272OtherPREFERRED ONE