1720080807 NPI number — GREGORY M GOTTSCHLICH MD

Table of content: GREGORY M GOTTSCHLICH MD (NPI 1720080807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720080807 NPI number — GREGORY M GOTTSCHLICH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOTTSCHLICH
Provider First Name:
GREGORY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720080807
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4260 GLENDALE MILFORD RD STE 1007
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLUE ASH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45242-3763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-619-9229
Provider Business Mailing Address Fax Number:
513-386-7926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4260 GLENDALE MILFORD RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45242-3763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-769-2762
Provider Business Practice Location Address Fax Number:
513-769-2769
Provider Enumeration Date:
06/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  35-04-8567G , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 311485449 . This is a "CIGNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 311485449 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 48567 . This is a "HUMANA CHOICE CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: UNITED HEALTH CARE . This is a "311485449" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 311485449 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000021081 . This is a "ANTHEM BLUE CROSS BLUE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 311485449 . This is a "TRICARE/CHAMPUS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 40011112 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 549482 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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