Healthcare Provider Details

I. General information

NPI: 1417490293
Provider Name (Legal Business Name): MELISSA GOTTSCHLICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4260 GLENDALE MILFORD RD SUITE 201
BLUE ASH OH
45242-3763
US

IV. Provider business mailing address

4260 GLENDALE MILFORD RD SUITE 201
BLUE ASH OH
45242-3763
US

V. Phone/Fax

Practice location:
  • Phone: 513-619-9229
  • Fax:
Mailing address:
  • Phone: 513-619-9229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.004917RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: