Provider Demographics
NPI:1447359856
Name:GOTTLIEB/ WEST TOWNS PHO, INC.
Entity type:Organization
Organization Name:GOTTLIEB/ WEST TOWNS PHO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER-WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-450-4943
Mailing Address - Street 1:675 W NORTH AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1634
Mailing Address - Country:US
Mailing Address - Phone:708-450-4945
Mailing Address - Fax:708-450-1150
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-450-4945
Practice Address - Fax:708-450-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization