Basic Information
Provider Information | |||||||||
NPI: | 1891718383 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOTTSMAN | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | BRADLEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1000 JOHNSON FERRY RD | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303421611 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043002476 | ||||||||
FaxNumber: | 4042508010 | ||||||||
Practice Location | |||||||||
Address1: | 1475 JESSE JEWELL PKWY NE STE 302 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 305013806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702926500 | ||||||||
FaxNumber: | 7702926535 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 08/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 050102 | GA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 10062469 | 01 | GA | AMERIGROUP | OTHER | P00339111 | 01 | GA | RR MEDICARE-GRP # CC4177 | OTHER | 7444426 | 01 | GA | CIGNA | OTHER | 000908872D | 05 | GA |   | MEDICAID | 0900422 | 01 | GA | UHC | OTHER | 000908872C | 05 | GA |   | MEDICAID | 339832 | 01 | GA | WELLCARE | OTHER | 52864125 | 01 | GA | BCBS | OTHER |