Provider Demographics
NPI:1649242124
Name:GOTTLIEB, CARY A (MD)
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:A
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 US HIGHWAY 41 W
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2252
Mailing Address - Country:US
Mailing Address - Phone:906-225-3964
Mailing Address - Fax:906-226-3875
Practice Address - Street 1:3401 LUDINGTON ST
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1300
Practice Address - Country:US
Practice Address - Phone:906-226-9127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406387207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4194270Medicaid
MI220520070OtherBLUE CROSS BLUE SHIELD MI
MI4194270Medicaid
220028718Medicare PIN
MI220520070OtherBLUE CROSS BLUE SHIELD MI