Provider Demographics
NPI:1679542336
Name:GOTSCHLICH, EMIL C (MD)
Entity Type:Individual
Prefix:
First Name:EMIL
Middle Name:C
Last Name:GOTSCHLICH
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 1:100 FODEN RD W
Mailing Address - Street 2:STE 203
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:SUITE 900
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-874-2445
Practice Address - Fax:207-523-8598
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013019207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1040568OtherAETNA
030422OtherANTHEM
ME291620099Medicaid
F01892Medicare UPIN
MM3927Medicare ID - Type Unspecified
ME291620099Medicaid
MEMM392701Medicare PIN