MEDICARE: DR. CHARLENE GOTTLIEB 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	R6417	MO

General Provider Information

NPI Number	:	1700990942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLENE GOTTLIEB M.D.

Provider Business Mailing Address
First Line	:	8000 BONHOMME AVE
Second Line	:	SUITE 104
City	:	CLAYTON
State	:	MO
Zip	:	63105-3515
Country	:	US
Telephone Number	:	314-725-8220
Fax Number	:

Provider Business Practice Location Address
First Line	:	8000 BONHOMME AVE
Second Line	:	SUITE 104
City	:	CLAYTON
State	:	MO
Zip	:	63105-3515
Country	:	US
Telephone Number	:	314-725-8220
Fax Number	:

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	07/08/2007

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