Provider Demographics
NPI:1720080807
Name:GOTTSCHLICH, GREGORY M (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:M
Last Name:GOTTSCHLICH
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 1:4260 GLENDALE MILFORD RD STE 1007
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-3763
Mailing Address - Country:US
Mailing Address - Phone:513-619-9229
Mailing Address - Fax:513-386-7926
Practice Address - Street 1:4260 GLENDALE MILFORD RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-3763
Practice Address - Country:US
Practice Address - Phone:513-769-2762
Practice Address - Fax:513-769-2769
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-8567G174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311485449OtherCIGNA
OH311485449OtherAETNA
OH48567OtherHUMANA CHOICE CARE
OHUNITED HEALTH CAREOther311485449
OH311485449OtherHEALTH ALLIANCE
OH000000021081OtherANTHEM BLUE CROSS BLUE
OH311485449OtherTRICARE/CHAMPUS
OH40011112OtherMEDICARE RAILROAD
OH549482Medicaid
OH48567OtherHUMANA CHOICE CARE
OHUNITED HEALTH CAREOther311485449