MEDICARE: MICHAEL M GELBORT INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	07100400	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9904511	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1083749451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL M GELBORT INC

Provider Business Mailing Address
First Line	:	2714 CATON FARM RD
Second Line	:
City	:	JOLIET
State	:	IL
Zip	:	60435-1309
Country	:	US
Telephone Number	:	815-230-2262
Fax Number	:

Provider Business Practice Location Address
First Line	:	2714 CATON FARM RD
Second Line	:
City	:	JOLIET
State	:	IL
Zip	:	60435-1309
Country	:	US
Telephone Number	:	815-230-2262
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL M GELBORT
Credential	:	PHD
Telephone Number	:	815-230-2262

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	02/14/2014

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