Provider Demographics
NPI:1376870501
Name:MARC E GOTTLIEB MD PC
Entity Type:Organization
Organization Name:MARC E GOTTLIEB MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-252-3354
Mailing Address - Street 1:PO BOX 86040
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-6040
Mailing Address - Country:US
Mailing Address - Phone:602-252-3354
Mailing Address - Fax:602-252-2367
Practice Address - Street 1:1012 E WILLETTA ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2749
Practice Address - Country:US
Practice Address - Phone:602-239-6040
Practice Address - Fax:602-252-2367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ200392086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ053025Medicaid
A50979Medicare UPIN