Individual
DR. GLENN RICHARD GOURLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
3001 BROADWAY ST NE STE 500, MINNEAPOLIS, MN 55413-2197
(612) 871-1145
(612) 870-5491
Mailing address
PO BOX 14909, MINNEAPOLIS, MN 55414-0909
(612) 871-1145
(612) 870-5491
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
48367
MN
2080P0206X
Pediatric Gastroenterology Physician
48367
MN
2080P0206X
Pediatric Gastroenterology Physician
Primary
E-10741
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1046326
PREFERRED ONE
MN
05
—
1511089
—
IA
01
—
182562
UCARE
MN
05
—
220820200
—
MN
01
—
29-00053
MEDICA PRIMARY
MN
01
—
29-00477
MEDICA CHOICE
MN
01
—
730T5GO
BCBS
MN
Enumeration date
07/06/2006
Last updated
06/05/2019
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