Healthcare Provider Details

I. General information

NPI: 1295805778
Provider Name (Legal Business Name): MICHAEL M GELBORT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2714 CATON FARM RD
JOLIET IL
60435-1309
US

IV. Provider business mailing address

PO BOX 437
HIGHLAND PARK IL
60035-0437
US

V. Phone/Fax

Practice location:
  • Phone: 815-230-2262
  • Fax: 815-230-2444
Mailing address:
  • Phone: 815-230-2262
  • Fax: 815-230-2444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number07100400
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: