MEDICARE: DR. EDWARD MARVIN GOTLIEB MD

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	2080A0000X	Pediatric Adolescent Medicine Physician	014500	GA

General Provider Information

NPI Number	:	1093713356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD MARVIN GOTLIEB MD

Provider Business Mailing Address
First Line	:	5405 MEMORIAL DR
Second Line	:	BUILDING D
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-3234
Country	:	US
Telephone Number	:	404-296-3800
Fax Number	:	404-297-8753

Provider Business Practice Location Address
First Line	:	5405 MEMORIAL DR
Second Line	:	BUILDING D
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-3234
Country	:	US
Telephone Number	:	404-296-3800
Fax Number	:	404-297-8753

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

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	09/28/2011

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