Provider Demographics
NPI:1427210491
Name:GLEN GABRIELSON
Entity Type:Organization
Organization Name:GLEN GABRIELSON
Other - Org Name:DOTHAN FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GABRIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-794-6504
Mailing Address - Street 1:1891 HONEYSUCKLE RD
Mailing Address - Street 2:STE 2
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4290
Mailing Address - Country:US
Mailing Address - Phone:334-794-6504
Mailing Address - Fax:334-793-4452
Practice Address - Street 1:1891 HONEYSUCKLE RD
Practice Address - Street 2:STE 2
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-4290
Practice Address - Country:US
Practice Address - Phone:334-794-6504
Practice Address - Fax:334-793-4452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1427210491Medicaid
AL1427210491Medicaid