=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952699571
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHIRA M. GELB O.D. L.L.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2011
-----------------------------------------------------
Last Update Date | 02/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3104 W DEVON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60659-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-764-3937
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1973 BURR OAK LN
-----------------------------------------------------
City | HIGHLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60035-4201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SHIRA M GELB
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 773-719-3827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046009648
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------