MEDICARE: MICHAEL M GELBORT PHD

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00057668	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	9904511	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1295805778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL M GELBORT PHD

Provider Business Mailing Address
First Line	:	PO BOX 437
Second Line	:
City	:	HIGHLAND PARK
State	:	IL
Zip	:	60035-0437
Country	:	US
Telephone Number	:	815-230-2262
Fax Number	:	815-230-2444

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	:	815-230-2444

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/08/2007

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