Provider Demographics
NPI:1275573438
Name:GOTTLIEB, HERMAN (DO)
Entity Type:Individual
Prefix:
First Name:HERMAN
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 820933
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-926-9010
Mailing Address - Fax:215-226-8286
Practice Address - Street 1:6557 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19149-2918
Practice Address - Country:US
Practice Address - Phone:215-535-1900
Practice Address - Fax:215-535-7950
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-001848-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0160469801Medicaid
PA597586OtherMEDICARE GROUP
D66332Medicare UPIN
PA0160469801Medicaid