Provider Demographics
NPI:1952326712
Name:BURLESON, GLENN E (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:E
Last Name:BURLESON
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 30031
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1031
Mailing Address - Country:US
Mailing Address - Phone:850-478-1312
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:1000 W MORENO ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2316
Practice Address - Country:US
Practice Address - Phone:850-478-1312
Practice Address - Fax:850-747-4906
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26708208600000X
FLME95535208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278057700Medicaid
FL42054OtherBLUE CROSS BLUE SHIELD OF FLORIDA
AL108535Medicaid
AL592-05635OtherBLUE CROSS BLUE SHIELD OF ALABAMA
A95174Medicare UPIN
MNA95174Medicare UPIN
FLAC974WMedicare PIN
AL108535Medicaid
FL278057700Medicaid