Basic Information
| Provider Information | |||||||||
| NPI: | 1114925138 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTLIEB | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 KENDRICK ST | ||||||||
| Address2: | STE 102 | ||||||||
| City: | NEEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024942726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172443322 | ||||||||
| FaxNumber: | 6172441827 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 KENDRICK ST | ||||||||
| Address2: | STE 102 | ||||||||
| City: | NEEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024942726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172443322 | ||||||||
| FaxNumber: | 6172441827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 9803 | NH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 014771 | ME | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | 36020 | MA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0805X | 9803 | NH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0805X | 014771 | ME | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0800X | 36020 | MA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | M08983 | 01 | MA | BLUE CROSS AND BLUE SHIEL | OTHER | 0180653 | 05 | MA | MEDICAID | 3112961 | 05 | NH | MEDICAID |