Basic Information
| Provider Information | |||||||||
| NPI: | 1821024936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOTTLIEB | ||||||||
| FirstName: | JEROME | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 N DUKE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176022250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175445511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 N DUKE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176022250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175445511 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 10/07/2009 | ||||||||
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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 | 2084P0800X | MD032172E | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 50055865 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 3550126000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 001518983 | 01 | PA | CBHNP | OTHER | 001518983 | 05 | PA | MEDICAID | 000405053 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 246547000 | 01 | PA | MAGELLAN | OTHER | 1577264 | 01 | PA | GATEWAY | OTHER | P00003237 | 01 | PA | RAILROAD MEDICARE | OTHER | 1150002 | 01 | PA | AETNA | OTHER |