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1689606287

NPI Code Detail

MEDICARE: DR. GLENN RICHARD GOURLEY M.D.

MEDICARE: DR. GLENN RICHARD GOURLEY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	48367	MN
2	2080P0206X	Pediatric Gastroenterology Physician	48367	MN
3	2080P0206X	Pediatric Gastroenterology Physician	E-10741	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	29-00053	OTHER	MN	MEDICA PRIMARY
2	1046326	OTHER	MN	PREFERRED ONE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	730T5GO	OTHER	MN	BCBS
5	182562	OTHER	MN	UCARE
6	29-00477	OTHER	MN	MEDICA CHOICE
7	29-00053	OTHER	MN	MEDICA CHOICE
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689606287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN RICHARD GOURLEY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 14909
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-0909
Country	:	US
Telephone Number	:	612-871-1145
Fax Number	:	612-870-5491

Provider Business Practice Location Address
First Line	:	3001 BROADWAY ST NE STE 500
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-2197
Country	:	US
Telephone Number	:	612-871-1145
Fax Number	:	612-870-5491

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	06/05/2019

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Directions to “ DR. GLENN RICHARD GOURLEY M.D.” Practice Location

Language	Start Address	Practice Location

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