Healthcare Provider Details

I. General information

NPI: 1649250382
Provider Name (Legal Business Name): NEIL BRUCE GOTTLIEB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2137 WELSH RD SUITE 2D
PHILADELPHIA PA
19115-4963
US

IV. Provider business mailing address

8100 ROOSEVELT BLVD SUITE 101
PHILADELPHIA PA
19152-2900
US

V. Phone/Fax

Practice location:
  • Phone: 215-698-7333
  • Fax: 215-673-9492
Mailing address:
  • Phone: 215-335-5355
  • Fax: 215-335-5352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD072671L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: