MEDICARE: MARC E 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	2086S0122X	Plastic and Reconstructive Surgery Physician	20039	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275521635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARC E GOTTLIEB M.D.

Provider Business Mailing Address
First Line	:	1012 E WILLETTA STREET
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85006
Country	:	US
Telephone Number	:	602-839-6040
Fax Number	:	602-839-4375

Provider Business Practice Location Address
First Line	:	1012 E WILLETTA STREET
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85006
Country	:	US
Telephone Number	:	602-839-6040
Fax Number	:	602-839-4375

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

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	07/01/2016

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