Glenn Richard Gourley, M.D.

Primary specialty

Pediatric Gastroenterology PhysicianTaxonomy code 2080P0206X

License

E-10741 Issued in AR

Practice address

3001 Broadway St NE Ste 500
Minneapolis, MN 55413-2197

Phone

(612) 871-1145

Fax

(612) 870-5491

NPI assigned

Jul 6, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 8

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://fhir.nextgen.com/nge/prod/fhir-api-r4/fhir/r4/
• Direct secure messaging: glenngourley@mklt.allscriptsdirect.net

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Mankato Clinic LTD

  • Family Medicine Physician
  • Mankato, MN
  • NPI 1629044029

  Pediatrics

  Medicare reassignment NPD
• Mngi Digestive Health, P.a.

  • Gastroenterology Physician
  • Minneapolis, MN
  • NPI 1609804541
  Medicare reassignment NPD
• Fairview Health Services

  • Emergency Medicine Physician
  • Minneapolis, MN
  • NPI 1811077175
  Medicare reassignment
• Fairview Clinics

  dba Fairview Clinics - Integrated Primary Care

  • Clinic/Center
  • Minneapolis, MN
  • NPI 1043516867
  NPD
• Fairview Health Services

  dba Fairview Hospital University

  • General Acute Care Hospital
  • Minneapolis, MN
  • NPI 1013994359
  NPD
• Fairview Health Services

  dba Fairview Emergency Medical Services

  • Land Ambulance
  • Saint Paul, MN
  • NPI 1710212485
  NPD
• Mngi Endoscopy ASC Inc

  • Ambulatory Surgical Clinic/Center
  • Minneapolis, MN
  • NPI 1669496345
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152144000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1559692800000",
    "number": "1689606287",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 14909",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554140909",
            "telephone_number": "612-871-1145",
            "fax_number": "612-870-5491"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3001 BROADWAY ST NE STE 500",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554132197",
            "telephone_number": "612-871-1145",
            "fax_number": "612-870-5491"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GOURLEY",
        "first_name": "GLENN",
        "middle_name": "RICHARD",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-06",
        "last_updated": "2019-06-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "MN",
            "license": "48367",
            "primary": false
        },
        {
            "code": "2080P0206X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Pediatric Gastroenterology",
            "state": "MN",
            "license": "48367",
            "primary": false
        },
        {
            "code": "2080P0206X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Pediatric Gastroenterology",
            "state": "AR",
            "license": "E-10741",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA PRIMARY",
            "identifier": "29-00053",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PREFERRED ONE",
            "identifier": "1046326",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1511089",
            "state": "IA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "730T5GO",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UCARE",
            "identifier": "182562",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA CHOICE",
            "identifier": "29-00477",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICA CHOICE",
            "identifier": "29-00053",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "220820200",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jessica Lynn Gough-Olbekson
• Brian Stuart Gould, M.D.
• Robert Gould, MD
• Thomas Arley Goulding, DDS
• Julia A Gourde, RN, CNP
• Jenna Gove, DPT
• Naveen Krishne Gowda, M.D
• Dinesh K Goyal, MD
• Samarth Goyal
• Jennifer Gozy, PSYD, LP

• Pediatric Gastroenterology Physician in Minneapolis, MN
• Providers in Minneapolis, MN by specialty
• Pediatric Gastroenterology Physician in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 5, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.