Basic Information
| Provider Information | |||||||||
| NPI: | 1689606287 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOURLEY | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14909 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554140909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711145 | ||||||||
| FaxNumber: | 6128705491 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 BROADWAY ST NE STE 500 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554132197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711145 | ||||||||
| FaxNumber: | 6128705491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 48367 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0206X | 48367 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 2080P0206X | E-10741 | AR | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 29-00053 | 01 | MN | MEDICA PRIMARY | OTHER | 1046326 | 01 | MN | PREFERRED ONE | OTHER | 1511089 | 05 | IA | MEDICAID | 730T5GO | 01 | MN | BCBS | OTHER | 182562 | 01 | MN | UCARE | OTHER | 29-00477 | 01 | MN | MEDICA CHOICE | OTHER | 29-00053 | 01 | MN | MEDICA CHOICE | OTHER | 220820200 | 05 | MN | MEDICAID |