Basic Information
| Provider Information | |||||||||
| NPI: | 1952326712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURLESON | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30031 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325031031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504781312 | ||||||||
| FaxNumber: | 8504749060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 W MORENO ST | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325012316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504781312 | ||||||||
| FaxNumber: | 8507474906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 05/11/2010 | ||||||||
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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 | 208600000X | 26708 | MN | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | ME95535 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 278057700 | 05 | FL | MEDICAID | 42054 | 01 | FL | BLUE CROSS BLUE SHIELD OF FLORIDA | OTHER | 108535 | 05 | AL | MEDICAID | 592-05635 | 01 | AL | BLUE CROSS BLUE SHIELD OF ALABAMA | OTHER |