MEDICARE: KENNETH I. GOTTLIEB, M.D. A PROFESSIONAL CORPORATION

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	2084F0202X	Forensic Psychiatry Physician	G23013	CA

General Provider Information

NPI Number	:	1710123112
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH I. GOTTLIEB, M.D. A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	909 HYDE ST STE 430
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-4846
Country	:	US
Telephone Number	:	415-346-2103
Fax Number	:

Provider Business Practice Location Address
First Line	:	909 HYDE ST STE 430
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94109-4846
Country	:	US
Telephone Number	:	415-346-2103
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENNETH I GOTTLIEB
Credential	:	M.D.
Telephone Number	:	415-346-2103

Provider Enumeration Date	:	01/06/2009
Last Update Date	:	01/06/2009

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