Basic Information
| Provider Information | |||||||||
| NPI: | 1992713036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOTTLIEB | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 SHELBURNE RD | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069023628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032767298 | ||||||||
| FaxNumber: | 2033554842 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 SHELBURNE RD | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069023628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032767298 | ||||||||
| FaxNumber: | 2033554842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 10/10/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 041558 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2V4161 | 01 | CT | HEALTH NET | OTHER | 4630381 | 01 | CT | AETNA - PPO | OTHER | P3297973 | 01 | CT | OXFORD HEALTH PLAN | OTHER | 041558 | 01 | CT | EMPIRE BC/BS | OTHER | 010041558CT01 | 01 | CT | ANTHEM BC/BS | OTHER | 3432398 | 01 | CT | AETNA - HMO | OTHER | 4129498 | 01 | CT | CONNECTICARE | OTHER | P00209686 | 01 | CT | RAILROAD MEDICARE | OTHER |