Provider Demographics
NPI:1477748168
Name:GLENN E BURLESON MD PA
Entity Type:Organization
Organization Name:GLENN E BURLESON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BURLESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-444-9511
Mailing Address - Street 1:1717 N E ST
Mailing Address - Street 2:SUITE 532
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-6339
Mailing Address - Country:US
Mailing Address - Phone:850-444-9511
Mailing Address - Fax:850-444-9646
Practice Address - Street 1:1717 N E ST
Practice Address - Street 2:SUITE 532
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6339
Practice Address - Country:US
Practice Address - Phone:850-444-9511
Practice Address - Fax:850-444-9646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 95535208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAE479Medicare PIN