Provider Demographics
NPI:1821024936
Name:GOTTLIEB, JEROME (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
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 1:555 N DUKE ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2250
Mailing Address - Country:US
Mailing Address - Phone:717-544-5511
Mailing Address - Fax:
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:717-544-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032172E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50055865OtherCAPITAL BLUE CROSS
PA3550126000OtherINDEPENDENCE BLUE CROSS
PA001518983OtherCBHNP
PA001518983Medicaid
PA000405053OtherHIGHMARK BLUE SHIELD
PA246547000OtherMAGELLAN
PA1577264OtherGATEWAY
PAP00003237OtherRAILROAD MEDICARE
PA1150002OtherAETNA
PAP00003237OtherRAILROAD MEDICARE
PA1150002OtherAETNA