Provider Demographics
NPI:1588610646
Name:JOSEPH R GOTTESMAN, LLC
Entity Type:Organization
Organization Name:JOSEPH R GOTTESMAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-330-6886
Mailing Address - Street 1:2023 W GUADALUPE RD
Mailing Address - Street 2:STE 11-181
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-7371
Mailing Address - Country:US
Mailing Address - Phone:602-384-4170
Mailing Address - Fax:602-808-9778
Practice Address - Street 1:2023 W GUADALUPE RD
Practice Address - Street 2:STE 11-181
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-7371
Practice Address - Country:US
Practice Address - Phone:602-384-4170
Practice Address - Fax:602-808-9778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ230334Medicaid
AZ230334Medicaid
AZZ107444Medicare PIN