MEDICARE: PAUL S. GOTLIEB M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	34200	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0425224	OTHER	MN	MEDICA HEALTH PLAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1M593GO	OTHER	MN	BCBS OF MINNESOTA

General Provider Information

NPI Number	:	1578569042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL S. GOTLIEB M.D.

Provider Business Mailing Address
First Line	:	6545 CROSSTOWN AVE. S
Second Line	:	SUITE 150
City	:	EDINA
State	:	MN
Zip	:	55435
Country	:	US
Telephone Number	:	952-848-5600
Fax Number	:	952-848-5556

Provider Business Practice Location Address
First Line	:	6545 FRANCE AVE S
Second Line	:	SUITE 150
City	:	EDINA
State	:	MN
Zip	:	55435-2131
Country	:	US
Telephone Number	:	952-848-5600
Fax Number	:	952-848-5556

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	03/29/2012

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Directions to “ PAUL S. GOTLIEB M.D.” Practice Location

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