Basic Information
| Provider Information | |||||||||
| NPI: | 1376870501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARC E GOTTLIEB MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86040 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850806040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022523354 | ||||||||
| FaxNumber: | 6022522367 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 E WILLETTA ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022396040 | ||||||||
| FaxNumber: | 6022522367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2009 | ||||||||
| LastUpdateDate: | 11/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | GOTTLIEB | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6022523354 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | 20039 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 053025 | 05 | AZ | MEDICAID |