Healthcare Provider Details

I. General information

NPI: 1588600886
Provider Name (Legal Business Name): MICHAEL H GOTLIB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2830 CORUNNA RD
FLINT MI
48503-3254
US

IV. Provider business mailing address

4856 PANORAMA CIR
WEST BLOOMFIELD MI
48323-2475
US

V. Phone/Fax

Practice location:
  • Phone: 810-235-6812
  • Fax: 810-234-7022
Mailing address:
  • Phone: 248-496-5209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301035009
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: