MEDICARE: SUSAN 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	2085R0202X	Diagnostic Radiology Physician	201697	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952363988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN GOTTLIEB M.D.

Provider Business Mailing Address
First Line	:	150 E SUNRISE HWY
Second Line	:
City	:	LINDENHURST
State	:	NY
Zip	:	11757-2539
Country	:	US
Telephone Number	:	631-225-7200
Fax Number	:	631-930-9451

Provider Business Practice Location Address
First Line	:	150 E SUNRISE HWY
Second Line	:
City	:	LINDENHURST
State	:	NY
Zip	:	11757-2539
Country	:	US
Telephone Number	:	631-225-7200
Fax Number	:	631-930-9451

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

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	06/21/2012

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