Provider Demographics
NPI:1366629248
Name:GEORGE R GOTTLIEB, MD, PC
Entity Type:Organization
Organization Name:GEORGE R GOTTLIEB, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-979-3796
Mailing Address - Street 1:2675 N DECATUR RD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6131
Mailing Address - Country:US
Mailing Address - Phone:770-979-3796
Mailing Address - Fax:770-979-0939
Practice Address - Street 1:2675 N DECATUR RD
Practice Address - Street 2:SUITE 404
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6131
Practice Address - Country:US
Practice Address - Phone:770-979-3796
Practice Address - Fax:770-979-0939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020437207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD45452Medicare UPIN