1215462205 NPI number — MICHAEL S GOTTLIEB F.N.P-BC(ANCC) M.S.N

Table of content: MICHAEL S GOTTLIEB F.N.P-BC(ANCC) M.S.N (NPI 1215462205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215462205 NPI number — MICHAEL S GOTTLIEB F.N.P-BC(ANCC) M.S.N

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOTTLIEB
Provider First Name:
MICHAEL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
F.N.P-BC(ANCC) M.S.N
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:
1215462205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 PECONIC ST
Provider Second Line Business Mailing Address:
92A
Provider Business Mailing Address City Name:
RONKONKOMA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11779-7100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
929-430-7907
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 PECONIC ST
Provider Second Line Business Practice Location Address:
92A
Provider Business Practice Location Address City Name:
RONKONKOMA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11779-7100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-833-0696
Provider Business Practice Location Address Fax Number:
206-350-1094
Provider Enumeration Date:
04/27/2017

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: 363L00000X , with the licence number:  F-341691 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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