Basic Information
| Provider Information | |||||||||
| NPI: | 1134209489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTSCHALK | ||||||||
| FirstName: | STEPHEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 262 DANNY THOMAS PL # MS 515 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381053678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015953006 | ||||||||
| FaxNumber: | 9015953843 | ||||||||
| Practice Location | |||||||||
| Address1: | 262 DANNY THOMAS PL | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381053678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015953300 | ||||||||
| FaxNumber: | 9015953842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 12/01/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0207X | L2286 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 207RH0003X | L2286 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 208000000X | L2286 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | Q031338 | 05 | TN | MEDICAID | 146759901 | 05 | TX | MEDICAID |