Provider Demographics
NPI:1689606287
Name:GOURLEY, GLENN RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:RICHARD
Last Name:GOURLEY
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:PO BOX 14909
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-0909
Mailing Address - Country:US
Mailing Address - Phone:612-871-1145
Mailing Address - Fax:612-870-5491
Practice Address - Street 1:3001 BROADWAY ST NE STE 500
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2197
Practice Address - Country:US
Practice Address - Phone:612-871-1145
Practice Address - Fax:612-870-5491
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48367208000000X, 2080P0206X
ARE-107412080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN29-00053OtherMEDICA PRIMARY
MN1046326OtherPREFERRED ONE
IA1511089Medicaid
MN730T5GOOtherBCBS
MN182562OtherUCARE
MN29-00477OtherMEDICA CHOICE
MN29-00053OtherMEDICA CHOICE
MN220820200Medicaid
MNB53177Medicare UPIN
MN29-00053OtherMEDICA PRIMARY
WI30269000Medicare ID - Type UnspecifiedWI MA