Healthcare Provider Details

I. General information

NPI: 1447359856
Provider Name (Legal Business Name): GOTTLIEB/ WEST TOWNS PHO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 W NORTH AVE LOWER LEVEL
MELROSE PARK IL
60160-1634
US

IV. Provider business mailing address

675 W NORTH AVE LOWER LEVEL
MELROSE PARK IL
60160-1634
US

V. Phone/Fax

Practice location:
  • Phone: 708-450-4945
  • Fax: 708-450-1150
Mailing address:
  • Phone: 708-450-4945
  • Fax: 708-450-1150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MRS. ERICA PORTER-WALTON
Title or Position: CONTROLLER
Credential:
Phone: 708-450-4943