Provider Demographics
NPI:1619197498
Name:EDWARD M. GOTLIEB, M.D., ET AL DBA THE PEDIATRIC CENTER
Entity Type:Organization
Organization Name:EDWARD M. GOTLIEB, M.D., ET AL DBA THE PEDIATRIC CENTER
Other - Org Name:THE PEDIATRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOBBS
Authorized Official - Suffix:
Authorized Official - Credentials:ABA
Authorized Official - Phone:404-296-3800
Mailing Address - Street 1:5405 MEMORIAL DR
Mailing Address - Street 2:BUILDING D
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3234
Mailing Address - Country:US
Mailing Address - Phone:404-296-3800
Mailing Address - Fax:404-297-8753
Practice Address - Street 1:5405 MEMORIAL DR
Practice Address - Street 2:BUILDING D
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3234
Practice Address - Country:US
Practice Address - Phone:404-296-3800
Practice Address - Fax:404-297-8753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty