MEDICARE: DR. PHILIP D GOTTLIEB M.D.

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	2084P0800X	Psychiatry Physician	9803	NH
2	2084P0800X	Psychiatry Physician	014771	ME
3	2084P0805X	Geriatric Psychiatry Physician	36020	MA
4	2084P0805X	Geriatric Psychiatry Physician	9803	NH
5	2084P0805X	Geriatric Psychiatry Physician	014771	ME
6	2084P0800X	Psychiatry Physician	36020	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M08983	OTHER	MA	BLUE CROSS AND BLUE SHIEL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114925138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHILIP D GOTTLIEB M.D.

Provider Business Mailing Address
First Line	:	60 KENDRICK ST
Second Line	:	STE 102
City	:	NEEDHAM
State	:	MA
Zip	:	02494-2726
Country	:	US
Telephone Number	:	617-244-3322
Fax Number	:	617-244-1827

Provider Business Practice Location Address
First Line	:	60 KENDRICK ST
Second Line	:	STE 102
City	:	NEEDHAM
State	:	MA
Zip	:	02494-2726
Country	:	US
Telephone Number	:	617-244-3322
Fax Number	:	617-244-1827

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

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	02/16/2021

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